Iatrogenic Causes

On cat ladies and OB/GYN

2006-02-27T20:44:00.000-05:00

I just finished my grueling OB/GYN rotation and am to start Medicine tomorrow so I thought I would take a second to record my thoughts on the rotation just past, as well as the paltry few books I managed to squeeze in. Books first, babble after: Inspired by Carl Zimmer's fabulous (bugs & gross-out heavy) blog (link), I picked up his 4. Parasite Rex, a great look at the biology and pathophysiology and just creep-out fabulousness of some of the world's wildest non-free living lifeforms. I was driven to seek out his book after a brilliant post on toxoplasmosis (link), followed by an equally incredible post on wasps that can zombify roaches (link) I added him to my blogroll as well. Since ID continues to occupy a place in my heart (and in anxiety dreams about what the hell I am going to do with my life), I especially enjoyed it, but it's written at a level that anyone can get completely into it even without much biology background. His toxo article also served to remind me of the one written by Robert Sapolsky, which was a bright spot in an otherwise mediocre anthology of science writing that I read last year. The reminder served as enough of a push to look up what Mr. Sapolsky had been up to lately, which turned out to be 5. Monkeyluv : And Other Essays on Our Lives as Animals, a charming little collection of essays, the best of which focus on debunking popular understanding of genetics, a pet peeve of one of the few professors that I remember fondly from the pre-clinical time. When my brain was mush from night-shift labor & delivery, I read 5. Gil's All-Fright Diner, a little fluff of a horror-novel satire that helped me catch some giggles and even a few hours sleep even as the winter sun blazed in my window.
There were no giggles, though, in 6. Beasts of No Nation, an incredibly depressing first-person fictional account of the life of a child soldier in an unnamed African nation in the midst of brutal internecine conflict. It was pretty good, but that was almost beside the point, because after a grinding 15 hour day in the OR with my very malignant GYN surgery attending, a few pages of this book was all that was required to reduce me to hopeless mush. Not to mention, the pidgin that the protagonist, Agu, speaks in, felt false to me, especially having just finished Pediatrics and feeling especially attuned the the uniquely beautiful cadences of child speech. Other OB/GYN musings:

I loved delivering babies. I loved it despite the fact that it was far wetter & poopier (vaginal) and far bloodier (C-section) than I had expected. I loved being able to help people get through such a big event in their lives, and I loved that the women really liked their doctors.
I feel like outpatient OB/GYN can really be a blast - it's really nice to talk to people about ways that they can structure their lives to have healthy abies when they want them, and no babies when they don't. Related to this, my day at Planned Parenthood, an elective that only I out of my block of fellow MSIII's took advantage of, and the 2nd trimester abortion I witnessed were also very eye-opening, and make me all the more concerned about what is (or will be) going on in certain states.
On another note, some of my feminist concerns about the state of OB/GYN were hardly allayed by experiences with certain attendings & residents. While not malignant toward me, they were the kind of people, that given free rein sometimes become people that cross patriarchy-blaming blog entries get written about. I think, even more than the piece itself, which is the black-humored lightness that Twisty is great at, the heart-breaking comments from the women are what all med students should really read before getting all up in there with their speculums.
The malignancy of the surgery part of the rotation made me doubtful about my desire to complete a OB/GYN residency, however. If I could operate only with Dr. BigHands, a really nice attending who I worked with out at Io Hospital (It's a satellite of the Mecca where everything else happens, and where I did my Surgery rotation in November and December), then maybe, but seeing how badly even the 4th year residents got treated by some of the attendings made the whole deal very unappealing, and Family Medicine with a fellowship in OB/GYN much more appealing.
I sure as hell wish I had a better idea regarding the No Seriously, What The Hell Am I Going To Do With My Life-O-Meter (tm Dr. Fake Doctor of Ah, Yes). Sigh. It's getting freaking uncomfortably close (as in single-digit number of months) until I really have to decide, and I feel even more conflicted that I did starting 3rd year. I really need to find a mentor, or two, or three.

No 52 in '05... but maybe 46 in'06?

2006-01-22T19:45:00.000-05:00

So I'm re-starting the list, and I know I'm 3-odd weeks behind the rest of the known universe in refurbishing to welcome 2006, but that is about par for the course around here. I managed to make it to 45 books in '05, more counting the trashy paperbacks that lulled me to sleep on some nights, and even more counting the horrifyingly dry books for clerkships that flung me into sleep with a vengeance :). After all that, a few highlights:
Favorite read of the year: So hard to call it; I read some truly great books this year. I would probably end up calling it as a tie between 7. The Curious Incident of The Dog in the Nighttime, 23. Extremely Loud & Incredibly Close and 44. Garlic and Sapphires . One a memoir with food writing that can make you drool on your dress pants on the bus, the other two told by naif narrators that nonetheless expose holes in the day-today fabric of life in a beautiful and heart-rending way. Gosh.
Worst read:22. The Devil Wears Prada without a doubt one of the biggest waste of time reads of the year. Probably the only one on the list that made me think, "Hmm...I could have studied instead of reading that..."
Favorite MEDICAL books(or book bundle): Unable to pick just one again - so I went with a quintet that I pre-read before passing them off to my family. As the black science-sheep of my art-crazy family, Numbers 16. What I Learned in Medical School, 15. On Call: A Doctor's Days & Nights in Residency, 36. Letters to a Young Doctor, 35. Becoming a Doctor : A Journey of Initiation in Medical School and 39. Singular Intimacies formed a pretty great quintet to hand off (along with the inimitable The House of God) to them to explain what I was doing in the echoing hall of the hospital all day & all night.
Overhyped & Underwhelming: 26. Haunted despite being by one of my favorite authors, Chuck really seemed to be floundering in this gross-out poorly edited mess of a book. It just didn't do it for me and I'm afraid the bloom may be off the rose for my reading of his next work. I have something of a different feeling about 30. Harry Potter & the Half-Blood Prince , which, while I wasn't crazy about it, especially given all the hype, I am looking forward to the 6th book.

So with 45 down this past year, I'm hoping for 46 in '06... and a career decision, yikes! Plus maybe some more reflection on life on the wards. Time will have to tell for that latter one, though.
And now, the whole list, for posterity.
45. Son of a Witch 44. Garlic and Sapphires 43. Messenger Bird 42. A Primate's Memoir 41. Anansi Boys 40. Complications: A Surgeon's Notes on an Imperfect Science 39. Singular Intimacies 38. The Dog of the Marriage 37. Proof 36. Letters to a Young Doctor 35. Becoming a Doctor : A Journey of Initiation in Medical School 34. The Constant Gardner 33. Train Go Sorry 32. W;t 31. We Need to Talk About Kevin 30. Harry Potter & the Half-Blood Prince 29. Harry Potter & the Order of the Phoenix 28. Highway 61 Resurfaced 27. Mysterious Skin 26. Haunted 25. The Healing Art: A Doctor's Black Bag of Poetry 24. Emergency Sex and Other Desperate Measures 23. Extremely Loud & Incredibly Close 22. The Devil Wears Prada 21. Even Cowgirls Get The Blues 20. Autobiography of A Face 19. Truth & Beauty 18. Buying Dad 17. Neverwhere 16. What I Learned in Medical School 15. On Call: A Doctor's Days & Nights in Residency 14. The Best American Science and Nature Writing, 2004 13. Bee Season 12. Good Omens 11. Oryx & Crake 10. The Bonesetter's Daughter 9. Long for This World 8. The Pursuit of Alice Thrift 7. The Curious Incident of The Dog in the Nighttime 6. 2004's Best Science Writing 5. Out 4. Mendel's Dwarf 3. Heart Seizure 2. Ella Minnow Pea 1. The Girl in the Flammable Skirt

4 more weeks

2005-12-04T02:11:00.000-05:00

guten tag
Originally uploaded by Fib.

I've 4 more weeks left in the year to finish the last 10 books I would need to make my 52 books in a year goal complete. Given that the rigors of my Family Medicine rotation in Honduras and then the time demands of my rotation in Anasthesia and now General Surgery, have kept me from posting here for 8 weeks now, I'm not sure it is likely to happen. This is especially likely to be true as I have banned all Pre-Test and 1st Aid and other such study aids from the list. Ah well, a valiant effort nontheless perhaps.

Sad

2005-09-26T15:24:00.000-05:00

Almost at the end of the first clerkship of my 3rd year. The clerkship-that-is-not-a-clerkship is a smashed-together smörgåsbord of 3 weeks of outpatient medicine, 1 of newborn nursery, 2 of outpatient pediatrics, 1 of optho & ENT, and, in my case, 4 weeks of emergency medicine. My first week was at LowincomeExurb of SmallCity, and was perfectly fine. If anything, it was a lot like a drop-in primary care clinic that mysteriously has a high percentage of drunken patients. The attendings were super available and loved to teach. I didn't realize quite how good I had it and was champing the bit toward the 'real' emergencies at TraumaRama ED.

TraumaRama ED lies dead center in the medical complex of Small City and sees 50,000 patients a year. It's a whole new world. The people, like me, who chose to do 4 weeks of EM rather than just one, get the luck (?) of being paired with 3rd year residents rather than interns or 2nd years. The intent, of course, is for us to learn more though this pairing, and be able to visualize ourselves more easily in this profession. And while I feel like the learning is probably proceeding apace, my ability to visualize myself as anything other than dust beneath the feet of, well, anyone, is small, small small.

My resident was, er... strict. He hollered if I were to say, for example "This is Ms. P, a 45 year old woman coming in today with pain in...." because those 3 little words 'coming in today' slow down the FAST. FAST. FAST. pace that he likes to see the Emergency department run at. He paced circles around me while I tried to present to the attendings. He punched me hard, in the kidneys, to demonstrate how to assess for CVA tenderness. I've never seen anyone, including him, hit a patient that hard.

I began to stutter when I tried to talk, which I haven't done in years, not since extensive speech therapy in the pink & purple room in grade school. Blushing furiously, I apologized for stammering - he asked me what stammering was in a tone that suggested I has just cursed out his mother, and when I eked out 'the same as stuttering, basically', he barked at me not to apologize for stupid shit.

And I learned things, lots of things from him. And some small voice in me agreed every time he made me feel small. And I tried to console myself by thinking that he must have learned in this way, back when he was a MSIII at his BigIvyLeague med school. Isn't it good to learn the same way as folks in the 'Ivys do? All the same, right now I feel sad, because I wanted to love this clerkship unabashedly and I have been hating myself so much that I couldn't spare any emotion to love what I was a part of. And so it was with complete and utter shock that I heard last night that this resident - who I thought hated me, after all our shifts together, thought I was in the top 5% of my class.

Even now, I feel the flush burn my chest - there MUST be better ways than this - two weeks of feeling small as an ant mean that I'm good? My head will explode from cognitive dissonance if I think about it any more. There must be a better way. 1 more 10-12 hour shift left - a new resident this time because all of the others have left for a big confrence. I think I need some distance before I decide how I feel about this field, because right now how I feel about me is far too much in the way.

Leaping off the page...

2005-08-27T17:24:00.000-05:00

It's been a strange few weeks - the week of Emergency medicine was great fun, but draining, ENT was less fun, and very draining; now I am in outpatient medicine, which I think I would love if I wasn't such a moron about drugs. My school doesn't have a formal pharmacology course, and I never learned the non-generic names of many of the most common drugs in use, so when I am being pimped on this or that TradeName drug, I frequently gabble and stammer like an aphasic troll.

Also vertigo-inducing is the fact that my patients seem to be leaping off the page into the clinics. I finished reading W;t and then had an English professor at our local huge private university present to ENT clinic with chemo-induced tinnitus. Wit is famous to most from the HBO movie with the fabulous Emma Thompson, but I have soft spot in my heart for the little playlet in its book form, as that is how I first read it. My two favorite passages in the book both deal with language and medicine, subjects, as you might imagine, that remain close to my heart,

Vivian: I receive chemotherapy, throw up, am subjected to countless indignities, feel better, go home. Eight cycles. Eight neat little strophes. Oh, there have been the usual variations, subplots, red herrings: hepatotoxicity (liver poison), neuropathy (nerve death).
[Righteously] They are medical terms. I look them up. It has always been my custom to treat words with respect.
[...]
Medical terms are less evocative. Still, I want to know what the doctors mean when they... anatomize me. And I will grant that in this particular field of endeavor they possess a more potent arsenal of terminology than I. My only defense is the acquisition of vocabulary.

My real-life Vivian Bearing was a little less sharp and caustic than her literary counterpart, but no less attuned to words and their power. She sharply corrected the resident when he described her 'ringing' as a 'buzzing' in his presentation to the attending, and noted that she hardly thought there was a flock of bees behind her at any moment. I liked her very much, and (shamefully also rather liked seeing the somewhat awful and obstreperous resident with whom I worked that week wrong-footed for once.

I was reminded too, of my terrible, horrible patient in my last day of Pediatrics while reading We Need to Talk About Kevin, which I picked up after reading a recommendation on Flea's lovely book blog. I hope and pray the story of the little boy who I saw in clinic ends in a more happy way than this horror story. To give some context, the little boy was only 4, but he made even the 3rd year seasoned Pediatric resident come out of the room shaking! When you are a mere four years old yet travel with your own bouncer simply to keep you in physical control, have the horrible ingenuity to force your own hand down your throat to induce vomiting, and then to hold that vomitus in your mouth to spit at people in between screaming the foulest curses I have ever heard (INCLUDING work in a juvenile detention center)... well, things look bleak for a happy ending. I loved my outpatient pediatrics rotation, but it is this sad, horrible, little boy has stuck in my head with an eerie permanence rather than all of the wonderful parts.

The most recent book that has sent characters from its pages into the clinics was Train Go Sorry. In addition to being a captivating story of a woman my age finding her way and reflecting on a childhood that seemed unusual only in retrospect, this book educated me on Deaf life, and Deaf culture in a depth that is amazing in a memoir-style book. It's a bit embarrassing to admit how little I knew about Deaf culture and the many languages and schools within it, especially given the proximity of where I grew up in D.C. to Galludet University, which functions in the book as a kind of half lode-star/half holy grail. Into my preceptor's office on Wednesday whirls an incredibly friendly, completely non-verbal, profoundly Deaf man with diabetes raging so out of control that we almost ended up admitting him. There was no translator available, and the nurses had grown frustrated with his odd syntax in the note-writing communication style we had adopted, so when I went in and not only realized that he was writing in ALS syntax, but that if you spoke and wrote at the same time, he could lip read and get more meaning. The patient and I actually ended up developing a strong relationship, and as the compromise for not admitting him was that he come back every day for the rest of the week, I actually got a taste of having my 'own' patient. I also got a sour taste, though, as my preceptor, though voluble with praise for my ability to communicate with the patient, talked at him/past him/to me instead of him. As described so well in the book it was a moment when I experienced the dreadful impotence of the translator - incapable of making a connection between the two of them no matter how much I wished for it.

Where have you been?!

2005-08-06T13:53:00.000-05:00

'Where have you been?'
'Out!'
----
No, not really, but having just finished a stint in outpatient pediatrics where a lot of our population was high-risk teens (in the juvenile justice system, trying to be placed by Child/Youth Services, etc.), I am still channeling a bit of my teenage soul. I am not chanelling so much that I felt good about abandoning this entirely, however, which combined with the fact that I do want a record of my MSIII year to look back on, means that I hope to start this up again. I was away initially because of dire threats from my lovely girlfriend as to what might happen if I continued to blog and neglected my USMLE study efforts. Fear and studying took me out of commission through the end of June, and then a brief sojourn with selfsame fabulous helpmate to visit her family in Brasil finished off the last of my break. There seemed to be no time for anything but cleaning & pressing my white coat before beginning my time in the wacky and wonderful world of clinical medicine, which knocked me out til now, as the combination of staying late, getting up early, and celebrating promotions, the return of my board scores and a 3 year anniversary, and a rapidly dying laptop made getting on here to write a mammoth task. 9 weeks later. Enough excuses.
----
The books I managed to squeeze in had a strange way of reflecting the questions I have been getting, both in board prep and now, pimping questions. If not that, they are true enough to life to make me wish I had half the skills to describe my life that trenchantly.
During the run-up to the USMLE, I stole time to read Harry Potter V....

Hermione was much too pre-occupied these days to badger him about Occlumency. She was spending a lot of time muttering to herself and had not laid out any elf clothes for days. She was not the only person acting oddly as the O.W.L.s drew steadily nearer. Ernie MacMillan had developed an irritating habit of interrogating people about their study habits.
"How many hours d'you think you're doing a day?" he demanded of Harry and Ron as the queued outside Herbology, a manic gleam in his eyes. "I dunno," said Ron. "A few..." "More or less than eight?" "Less, I s'pose," said Ron, looking slightly alarmed. "I'm doing eight," said Ernie, puffing out his chest. "Eight or nine. I'm getting in an hour before breakfast every day. Eight's my average. I can do ten on a good weekend day. I did nine and a half on Monday. Not so good on Tuuesday - only seven and a quarter. Then on Wednesday --"
Harry was deeply thankful that Professor Sprout ushered them into greenhouse three at that point, forcing Ernie to abandon his recital.

I'm near certain my blog would have read like this had been been writing during this time, intersperesed with panic attacks rendered in print. All of the classmates I ran into seemed to have developed a touch of this irritating habit in late June, and those unfortunate souls whose fear of the exam caused them to wait until the day before orientation to take the boards were still suffering this ailment as we re-recited the Hippocratic oath. I feel particularly bad for a classmate, whose twin, far from being the kindred spirits of the Weasly twins, tortured him throughout studying by making my classmate feel like mud via superior kaplan scores, faster responses to pimping by their physician father, longer study hours, and other ugliness.

Non-reading studying breaks I watched episodes of House on my computer, which was great for the truly random diseases that test writers seem to love (SSPE anyone?), but my 52 books pursuit also sometimes yielded medially tangential results, as in Highway 61 Resurfaced. One of my favorite writers, Bill Fitzhugh, takes on a Delta Blues mystery, with slight side trips into the fabulous world of gonorrhea, where, in the process of murdering an old blues producer, a character named Crail has just been stabbed with a fork, and has a hot, painful swollen knee to show for it.

The truth of the matter was that Crail could have put the entire polar ice cap on his knee and it wouldn't have made any difference. And the reason for that went back to the summer of 1957 when Lamar Suggs paid five dollars to have his way with a huslin' gal of (ironically) Rolling Fork, Mississippi. This dalliance had resulted in a state-of-the-art case of gonorrhea for which Lamar eventually sought treatment and was cured. However, being the opportunistic bacteria that it is, the gram-negative intracellular diplococci had taken up residence, and lived happily for five decades in the membranes of his rancid old mouth, whence it migrated to every spoon & fork that passed his lips. [...]

He is given some random antibiotics by his equally evil girlfriend, but then the plot thickens.

He opened the glove comaprtment to look for the antibiotics Cuffie had given him, but it was too dark, so he turned on the car's interior light. That's when he noticed that the skin on the back of his hands has turned somewhat yellow and scaly. Inspecting both arms, Crail noticed a couple of eruptions and some peeling and, for a moment, wondered what that was all about.
It would turn out that it was all about something called sulfamethoxazole, one of the ingredients of the Bactrim he'd been taking at twice the prescribed dosage. Sulfamethoxazole can lead to a variety of interesting side effects, including progressive disintigration of the outer layer of the skin, liver damage, and weeping eruptions around the mouth, eyes and anus. Rooting through the glove compartment, Crail figured that whatever had caused the skin problems would probably respond to the antibiotics if he just took enough of them.

As you might imagine, things go from bad to worse at this point (although remembering the vivid description of the ADEs of Bactrim scored me a right answer on a pimping question earlier this week). Indeed, Crail is feeling much worse as he is robbing a lawyer's office later in the novel...

Chewing on three asprin, Crail looked down with red-rimmed eyes and said, "Guy stabbed me with a fork." Lynch gave him a sympathetic wince. "Ewww, man," he said. "That must have hurt like a sonofabitch." Crail nodded. "Hit the bone." "Ewww." He gestured at it. "Looks like it might be a little infected too." "Yeah, but I got some antibiotics." "Well, that's good," Lynch said. "Those things are great, a marvel of science."
While that much was true, one of the many things neither Crail nor Jeremy
Lynch knew was that when bacteria enters bone tissue (as had happened when Lamar Suggs sank that fork into Crail's knee), the resulting infection is known as osteomyelitis. And given that the proper treatment for that was a six-week course of penicillinase-resistant synthetic penicillin and a third-generation cephalosporin, it was going to do Crail precious little good to keep taking the Bactrim.

Now I just have to wait for a pimping question on osteomyelitis during my ER rotation next week, and the overdue fines on this book from the library will have paid for themselves.

Now with 200% more gay fruit flies

2005-06-03T13:23:00.000-05:00

T-3 weeks until the big day..... I'm a wreck and my brain is pathology soup, but I managed to mustered up enough neurons to be utterly wowed by this NY Times Article. I usually leave the genetics and social implications to the likes of Pharyngula & his amazing ID-smackdown posse, but this was too neat to pass up.

That one gene, the researchers are announcing today in the journal Cell, is apparently by itself enough to create patterns of sexual behavior - a kind of master sexual gene that normally exists in two distinct male and female variants.
In a series of experiments, the researchers found that females given the male variant of the gene acted exactly like males in courtship, madly pursuing other females. Males that were artificially given the female version of the gene became more passive and turned their sexual attention to other males.
"We have shown that a single gene in the fruit fly is sufficient to determine all aspects of the flies' sexual orientation and behavior," said the paper's lead author, Dr. Barry Dickson, senior scientist at the Institute of Molecular Biotechnology at the Austrian Academy of Sciences in Vienna.

I've never found much value in the nature v nurture debates over being a great big homo, but simply from a nifty biology standpoint, this is mindblowing - that a single gene can 'turn on' such a complex sequence of behavior. I will get back to our regularly scheduled program of talking about the medical aspects of awesome fiction and leave the gay sperm/gay flies/gay me paradigm behind.... as soon as I finish these next 100 multiple choice questions. Until then.

P.S. If you hate registering to read articles in the NY Times or elsewhere try looking for passwords at BugmeNot.

P.P.S. If you have anything valuable to do with your time in the next... oh... month, please, I beg of you, don't look at this game. Because I ignored a similar warning, I am now destined to waste oodles of time and get a 101 on the USMLE. Don't do it!

Dr. Andy, Gay Sperm and Homophobic Laws

2005-05-26T16:04:00.000-05:00

When Dr. Andy (one of the few folks in the medblogging world who I have actualy met in real life) wrote about the FDA's ban on "gay sperm", I found his response to be poorly informed, at best, and downright homophobic at worst. He said:

It is unfortunate that certain groups may be excluded, but the rules should be based on preventing disease transmission not political correctness. It should be noted that other groups, such as those who are adopted are also excluded from sperm donation.

I agree with him - policies SHOULD be based on preventing disease transmission. But since this policy does no such thing, I'm not sure how this qualifies as a supporting argument for the ban on so-called 'gay sperm'. Furthermore, entitling the post "Excessive Political Correctness" implies that people are upset about it for some wishy-washy 'politically correct' reason, rather than because it is non-evidence-based bad health policy. He gives lip service that there may be a "reasonable objection", but seems like he thinks overall the ban is a good idea. The fact that a screening question for blood donation is MSM sex, but NOT unsafe sex with a commercial sex worker seems to have informed this misguided sperm donation policy - that and the culture war that some of the political leaders today are leading against LGBT folks.
The American Council on Science and Health, a usually quite conservative body has this to say on the ban, from an article entitled Wanted: Scientific Reason for FDA's Gay Sperm Ban

I have searched through the medical literature for a sound scientific basis for this directive, yet the only reasoning behind the recommendation is the fact that homosexual men are at high risk of HIV. If this were the rationale, though, it follows that the FDA should bar other high-risk donors such as men who have used IV drugs or have had sex with prostitutes. This, however, is not the case. Considering the (increasingly) stringent testing procedures employed by sperm banks, the glaring inconsistency suggests the FDA is influenced by ideology, concerned more with sexual preference than with risky behavior.
[...]
What is accomplished by barring homosexuals from donating sperm? Does it save money? I don't see how. Will it save lives? Nope. Is it mere bias? It seems so, given the fact that while homosexual men do have a higher risk of HIV -- tests for which are now extremely accurate -- heterosexual men are by no means without risk. The policy seems to be a throwback to the days when HIV was deemed a "gay plague." I had hoped the FDA had made more progress than that.

It's nice to see someone actually doing the relevant literature review rather than paying than lip service to evidence based medicine, but then ignoring it when the non-evidence based reccomendations agree with your predjudices, as too many people do. The article ends by hoping "that the agency is not caving into pressure from homophobic moralists in its recommendation to bar sperm donations by gay men." I hope so too, but I'm afraid with even usually reasonable medbloggers like Dr. Andy being goofy on this issue, I don't have much confidence that this will be true - and what a shame it is that such an important national organization as the FDA has lost such complete touch with its scientific roots.

(ed. I know it's been almost 3 weeks since Dr. Andy's post - I'm studying for Step I, so some leeway is neccessary)

Self-exam to another level

2005-05-15T19:18:00.000-05:00

So I had this anxiety dream the other night where I was taking the boards and coming upon an anatomy question, started feeling myself up to see if I could remember which muscle produced the motion they were asking about. I really had been doing this while I was studying anatomy and I can't quite decide if it is an innovative way of linking my visuo/physical learning style or a good way to get kicked out of the exam. At any rate, in my dream, it was definitely the latter as this big Roald Dahl-style matron came and stood over me all irate and threatening me with irregularities and expulsion and failure to succeed EVER, etc, etc. And then she changed her mind and said that if I was going to "cheat using my body" I might as well be consistent about it. And then on the next question she made me do self bronchoalveolar lavage and culture so I could answer some micro question, and then handed me a lead lollipop for a tox question. And then I woke up. The only thing scarier than the dream itself is that I have spent the several days since then eyeing Q-bank with suspicion as to what horrible thing I might have to do to myself to answer it. If only the test were really like Doctor Dr. Quinn suggests - even though they may not have careers in test writing, many congrats to all the push fluids crew on the occasion of their graduation.
Though I haven't been writing (Qbank, review books and screaming along to riot grrl music taking up much of my time these days) I have been reading every night for the 30 minutes before bed, and have actually made my way through some awesome books. Most recent was Neil Gaiman's Neverwhere which I actually picked up thanks to a fabulous ChickLit review. It was the perfect companion to the intense Micro memorization I've been up to - engrossing, and delightful, and appropriately bleak (studying brain worms just doen't put one in the mood for sunny literature). I'm a longtime Neil Gaiman fan, but this one stood above the pack with tight plotting, and one of my favorite character types, the bumbing, hapless, nice, British guy. My girlfriend can't understand why any self-respecting dyke would watch Hugh Grant romantic comedies, but it's all due to fromative-year exposure to Arthur Dent, and a longtime love for lit or media detailing path and problems of the displaced citizen.
Prior to that were a pair of essay sets of the type that my grandmother, knowing nothing about medicine, but wanting to be supportive, contsantly buys me. On Call: A Doctor's Days & Nights in Residency was okay... but to tell the truth, I would much rather have read archives from The Underwear Drawer, Maria at Interui, or Dr. Scott over at Medea Sin. It wasn't that the book was bad, not at all. Dr. Transue is a talented writer.. it was just kind of... earnest, and predictable, and as much as I hate to say it... a little banal. The companion book that I got from the library at the same time was very different. What I learned in Medical School: Personal Stories of Young Doctors was great - the stories were fresh and sometimes heartbreaking - the standouts for me were the story by one of the editors of how he became homeless during his clinical years, a piece about serious sexual harrasment on a Surgery roation structured like a series of SOAP notes, and the biting tounge and cheek dissection of med school life by a lesbian mom. The sexual harrassment piece sent chills up & down my spine - I'm selecting clinical tracks as we speak and reading this didn't exactly do much to quell my anxiety on that front.

I just knew I'd never make it out of this surgery. I imagined a janitor stumbing onto my stiff frozen corpse sometime in the distant future, when the surgery was finally over.
"Are you paying attention? Dammit!" Dr. Snead's angry roar jerked me out of my daydream. It was one of the few times he'd even bothered to adknowledge my presence during the past 7 hours. It took me a minute to comprehend it was me he was talking to, not the resident. "Don't just stand there like an idiot! For G-d's sake, suction that blood already, honey! This isn't an orgasm, sweetheart, you can't just lie back and enjoy it!" His bellow reverberated through the OR. No one moved or said a word.

The few visibly queer folks I know at my school have done their surg rotations in community ORs rather than megamedcenter ones for some of these same fears/rumors about similar treatment... I really don't want to do that, but essays like that one make me wonder how much value I want to place on the 'courage of my convictions' versus escaping verbal abuse. Any advice from the small number of folks who read this would be much appreciated.

To Bleargh or not to Bleargh

2005-04-29T15:32:00.000-05:00

I'm a huge cranky ball of bleargh today - I'm behind on my schedule of USMLE study, nursing two huge throbbing hematomas where my lab partner busted up a pair of veins in our phlebotomy clinical skills session, and proud owner of a newly scratched all to hell MP3 player that got thrown to the floor of the bus when a huge bear of an undergrad slammed into me on a turn. So that's why I'm not writing - instead, a set of links having nothing to do with one another to take you round & about.

An incredible article about the radical redesign of something most of us take for granted - the prescription pill bottle. I share my apartment with my brother, who is an industrial designer and we both loved the design & the reasoning behind it, which says something for it, as we almost never agree on this sort of thing.
A terribly sad post by the brilliant writer of Cancer, Baby reveals that her ovarian cancer has recurred. She's been so strong & funny & brilliant in her sharing of her travel through cancer that it is just heartbreaking to read the news of her recurrence.
Lastly, I'm totally feeling Graham on the X-days-in, kill me now tip. Despite the death wish induced by studying, congrats on the new sweetheart - I know that my sweet & lovely girl is a big part of what's keeping me sane (relatively) through this mess and I hope your special someone will share nutella sandwiches with you upon the occasion of your rare surfacing.

French-kissing a Polar Bear

2005-04-24T13:52:00.000-05:00

I just finished my 14th book, the bookend/competitor to 2004's Best Science Writing, entitled The Best American Science and Nature Writing, 2004. I actually enjoyed it far more than the former - the essays were shorter, and sometimes lighter in hard science, but rather than being a negative, this was actually a plus for my Board Study-overloaded brain. The one essay that really blew my hair back was by self procalimed neuroscience "nerd" Robert Sapolsky who takes a handful of pages to meditate on the mind-control capabilities present in your average puddle. Well, not quite, but he does talk a bit about rabies and toxoplasmosis (both high-yield boards bugs as well - see, still studying!). The latter's description is hysterical, and unforgettable, so for the benefit of anyone else out there struggling through the list of bugs, I present his breakdown of the wierd and wooly Fatal Attraction-esque ways of Toxoplasma gondii.

In toxopasmic utopia, life consist of a two-host sequence involving rodents and cats. The protozoam gets ingested by the rodent, in which it forms cysts throughout the body, particularly in the brain. The rodent gets eaten by a cat, in which the toxoplasma organism reproduces. The cat sheds the parasite in its feces, which, in one of those circles of life, is nibbled by rodents. The whole scenario hinges on specificity: Cats are the only organism in which toxoplasma can sexually reproduce and be shed. Thus, toxoplasma wouldn't want its carrier rodent to get picked off by a hawk or its cat feces ingested by a dung beetle.
[...]
All good rodents avoid cats -- a behavior etholoist call a fixed-action pattern, in that the rodent doesn'd develop the aversion because of trial and error (since there aren't likely to be many opportunities to learn from one's errors around cats). Instead feline phobia is hard-wired. And it is accomplished through olfaction in the form of pheremones, the chemical odorant signals that animals release.
[...explanation of how toxoplasma infected rodents lose that aversion to/fear of cat pheremones...]
Now, this is not some generic case of a parasite messing with the head of an intermediate host and making it scatterbrained and vunerable. Everything else seems pretty intact in the rodents. [...] The rodents can still distinguish other odors. They simply don't recoil from cat pheremones. This is flabbergasting. This is akin to someone getting infected with a brain parasite that has no effect whatsoever on the person's thoughts, emotions, SAT scores, or television preferences but, to complete its life cycle, generates an irresistible urge to go to the zoo, scale a fence and
try to French-kiss the pissiest-looking polar bear.

Heh. I like diabolical organisms like that, and I especially like great science writing that means one less life-cycle to brute-force memorize. Unfortunately, I don't have great stories for all of the bugs so I had best get back to it.

Full of....

2005-04-22T19:17:00.000-05:00

To get away from the prevailing bookworm-nature that has marred this blog from the beginning, I thought I'd take a moment to behave a lot more like your average medical student, posting photos from the New England Journal of Medicine and taking time to comment on them with absolutely no trace of sophomoric humor or gross-out schadenfreude. That describes all the medical students you know, right?

Yah. So, back in the real world, I was experiencing one of the few true pleasures of life as a MSII - the casting & splinting clinical skills workshop. My lab partners were a fabulous woman with a sense of humor for days and a HUGE and sweet guy who knows the theme songs to nearly every cartoon from the 1980s and is willing to sing them at almost no provocation. The two of them together is like the guilty pleasure of Saturday morning in front of the TV with a big bowl of sugary cereal combined with whip-smart perfectionist souls that will make both of them great docs. No, neither of them were the problem. The problem wasn't even the totally goofy idea that they came up with, which was proposed with much giggling after I finished encasing my partner R's arm in a fiberglass cast (J's had already been done as an example of how to do it well by one of the ortho residents presiding over the affair). The upshot was that they wanted their casted arms... casted together... so it looked like they were locked in chopsocky movie style combat. We called over the most laid-back of the ortho residents to make sure he wouldn't be pissed at us for wasting supplies, and when he professed not to care, I set to binding their casted arms together as strongly & smoothly as possible with a 4-inch roll of fiberglass.

It was awesome. They ran around the lab showing people until the decidedly NOT laid-back ortho attending saw them and made them saw it off - which was the ending we had all been expecting, sooner or later.

No, none of this was the problem. The problem came from the other half of our small group, which has as one of its members a man so competitive that he makes Tiger Woods like someone who doesn't really see the value of competition, and so full of himself that he could probably give lessons to the male peacocks at the zoo. None of this would be so bad if he weren't given to talking out of the orifice that the man in the photo above (bet you didn't think I'd get back to that, huh?) hasn't used in ages. He is so full of it that not only are his eyes brown, but I'm convinced he used to be a redhead instead of a brunette before that stuff started reaching his cranial vault.

This ever so well informed gentleman takes it upon himself to share with me all the ways that I casted two people's arms together wrong. That he knows a lot about casting (two peoples arms together??) because "my-dad-the-cardiologist" (one word) got him all these great shadowing opportunities over the summer with blee de blah de blah and how his technique is so obviously superior. This would have been par for the course for him if he hadn't gone beyond words this time, by trying to GRAB the cast saw out of my hands while I was cutting the cast off of my lab partner, explaining that cutting open such a "ridiculously made" cast would take far too long and he deserved to use it first because his cast was just. that. good. And even that wouldn't have been SO outrageous if he hadn't jerked the saw right as I was finishing opening the part around the hand - causing the hot metal to touch my friends hand and give her a nasty blister. She was livid and I wasn't far behind her - but all wasn't over yet. The laid-back fellow had come across the peacock's casting partner while the the saw wrestling had been going on, and shouted over to ask who had done the cast. The peacock strutted over, sure he was bout to be commended on his excellent technique. The fellow took him apart. The foot was twisted and plantarflexed and there were ridges in his fiberglass that would cause pressure ulcers and his cuffs were sloppy and..... The peacock started stuttering bull explanations like "But out west I know some people prefer dorsiflexed for more stability blee de blah...." The fellow cut him off and said, with absolutely no expression: "This is a club. And you are full of shit. Go watch someone else do it for a while before you try to tell me my job." The wild cheers inside the heads of my lab-partners were reflected in their eyes, and I found my joy when I stumbled across this photo that perfectly expresses the metaphorical state of the poor peacock's soul.

Ah, medical school. Where bitching & biochemistry co-exist side by side. Back to the board review books for me.

P.S. The actual caption to the photo above is not my cranky rant, but rather:

A 49-year-old man with a history of paraplegia due to poliomyelitis, surgical treatment of a lumbar ependymoma, and chronic renal insufficiency due to a neuropathic bladder was admitted to the intensive care unit because of abdominal pain, vomiting and diarrhea, and hyperkalemia (serum potassium,7 mmol per liter). Computed tomography of the abdomen showed a severe fecal impaction with marked compression of the abdominal viscera without any sign of colonic perforation. After rehydration and correction of the hyperkalemia, the patient underwent manual disimpaction under general anesthesia. His recovery was unremarkable.

I can be mature sometimes, despite being a medical student.

Vanishing Lung Syndrome

2005-04-21T22:29:00.000-05:00

In trying to manage at least one post for April, I noticed through the fog of USMLE Step 1 study that this is National Poetry Month - and I thought I would share with you a little-known but really fabulous book of poems by a Czech author, Miroslav Holub. My favorite collection of poetry by him is called Vanishing Lung Syndrome. Below I copied a snippet from the title poem:

[...] scintigraphy shows
a disappearance of perfusion, and angiography
shows remnants of arterial branches
without the capillary phase.
Inside there may be growing
an abandoned room. [...]

This collection was written while Czechoslovakia was under Communist rule, and many of the poems are both medical and political at once - Holub taking advantage of his prodigious talent for wordsmithing to take jabs at the corruption and apathy within the ruling system.

In another poem entitled Kuru, or the Smiling Death Syndrome, the target is his fellow citizens:

We aren't the Fores of New Guinea
we don't indulge in ritual cannibalism
we don't harbour the slow virus that
causes degeneration
of the brain and spinal cord with spasms, shivers,
progressive dementia and
the typical grimace

We just smile,
embarrassed, we smile,
embarrassed, we smile,
embarrassed, we smile.

And for anyone who read the first line of this and went Eeeurgh, poetry - not only was Holub an accomplished immunologist & pathologist - he also had this to say about his career as a poet:

"I prefer to write for people untouched by poetry. . . . I would like them to read poems in such a matter-of-fact manner as when they are reading the newspaper or go to football matches. I would like people not to regard poetry as something more difficult, more effeminate or more praiseworthy." (Vecerní Praha, 1963)

P.S. For those who are curious, both Vanishing Lung Syndrome [2] and Kuru are real diseases, and just the kind of zebras that the Boards love to throw at innocent MSIIs. So I'm studying, really, I am.

Hitting my two-digit stride...

2005-03-26T14:52:00.000-05:00

With a low-two-digit number of weeks left until I take Step 1 of the Boards, I have also finally hit my two-digit stride in the 50-books challenge. And while I haven't been writing here that much, I'm excited to say that I received my first ever monetary reward for writing, in the form of a $100 prize for a piece written about my experience working at an AIDS hospice run by Buddhist monks and an overworked misanthropic Belgian doctor. So even though I haven't been writing as much here, I have been writing in general, and since no-one other than me reads this, that's just as good. The books I've been reading seem to be clustering themselves in natural dyads - I don't quite know what's driving it. The ususal driving force behind my reading selections is my local favorite punk-rock librarian at my huge (industrial-age-giant endowed) city library, but she has been AWOL for almost a month, leaving me with the decidedly unsatisfactory substitute of a librarian who insists on recommending Clive Barker thrillers with maniacal doctors on the cover and any book with 'bone' in the title (see 10. The Bonesetter's Daughter by Amy Tan). There have been some jewels among the unrewarding dross, however, including 8. The Pursuit of Alice Thrift - Elinor Lipman & 7. The Curious Incident of The Dog in the Nighttime - Mark Haddon.

The former chronicles poor, unlucky, unfriendly and unsocializable Alice Thrift, miserable in the 1st year of her surgical residency as well as in the rest of her life (what rest of her life?). I'm looking forward to finding the Alice Thrift character in tomorrow's premier of Grey's Anatomy - I'm hoping the show exceeds my expectations in the same way the book did, by both being funnier and more on target than it has any right to be. The scene where Alice sets herself up for the rest of the plot (by failing so spectacularly that she spends the remainder of the novel recovering in ways both heartening & hysterical) is true enough to life that I made a 3rd year friend of mine choke on her 11th coffee of the day just by reading it to her over the phone.

Let me begin by saying that it was my 30th hour of duty, every one of them on my feet. The sun had rise, set then risen again when I was summoned to the OR for the lowly job of holding a retractor during a gallbladder operation. Defensible or not, I dozed off - I swear, for one second - and lost my grip. My rebounding retractor hot the surgeons hand, causing damage I don't particularly want to discuss. Blood spurted everywhere. The surgeon screamed. He swore. He threw something sharp across the operating field, missing me, everyone claimed, on purpose. The patient didn't exsanguinate or die. But it was bad.

Poor Alice is not helped by the fact that she is awkward, to say the least. So much so that her mother is constantly advancing on her with well-highlighted articles on Asperger's syndrome, and her roommate is driven to wonder aloud if she is an alien anthropologist on a number of occasions. Alice's awkwardness eventually turns out to be from causes non-biochemical, and mostly the result of many years of loneliness, but not before providing more spit-take moments like this one.

"You don't have to worry. I practice diplomacy all the time with patients. A doctor can't just walk into the hospital room and say, "Looks bad. Couldn't be worse. Do you have your affairs in order?" The one time I did that, the family asked that I be taken off the case."
"I'm glad to hear that," my mother said. "At least it shows you have a feedback mechanism."

The too-neat ending (I won't spoil it for you) and the overwhelming fluffiness did somewhat diminish the pleasure of the book, but these were compensated for the other book in the Autism/Asperger's dyad, The Curious Incident of The Dog in the Nighttime. This book had all the seriousness that the other could want, but, amazingly without sacrificing any of the humor. It also has some of the best descriptions of sensory overload, lack of attentional filter and interpretive rigidity that I've ever seen - certainly better than the pathetic ones delivered by my equally pathetic Behavioral Sciences block instructor. As someone who worked in a weekly physical therapy setting with numerous profoundly Autistic children for 4 years, I can say without a doubt that calling Autistic children "distractable and hard to interact with" prepares a clinician to deal with them about as well as describing a schizophrenic as "imaginative and given to preoccupations" would. At any rate, one of my favorite scenes in the books deals with the sensory overload of a busy London train station on the main character, but is really worth picking up the book to read. My second favorite scene comes when the main character is trying to explain why new places are so tiring to him, with the help of his incredible teacher, Siobhan.

...But most people are lazy. They never look at everything. They do what is called glancing, which is the same word for bumping off of something and carrying on in almost the same direction, e.g. when a snooker ball glances off another snooker ball. And the information in their head is really simple. For example, if they are in the countryside, it might be:
I am standing in a field that is full of grass.
There are some cows in the fields.
It is sunny with a few clouds.
There are some flowers in the grass.
There is a village in the distance.
There is a fence at the edge of the field and it has a gate in it.
And then they would stop noticing anything because they would be thinking something else like, 'Oh it is very beautiful here,' or 'I'm worried that I might have left the gas cooker on,' or 'I wonder if Julie has given birth yet' (This is really true because I asked Siobhan what people thought about when they looked at things, and this is what she said.)
But if I am standing in a field, I notice everything. For example, I remember standing in a field on Wednesday, 15 June 1994, because Father and Mother and I were driving to Dover to get a ferry to France and we did what Father called, Taking the Scenic Route, which means going by little roads and stopping for lunch in a pub garden and I had to stop to go for a wee, and I went into a field with cows in it and after I'd had a wee I stopped and looked at the field and noticed these things
There are 19 cows in the field, 15 of which are black and white and 4 of which
are brown and white.
There is a village in the distance which has 31 visible houses and a church with a square tower and not a spire.
There are ridges in the field which means that in medieval times it was what is called a ridge and furrow field and people who lived in the village would have a ridge each to do farming on.
There is an old plastic bag from Asda in the hedge and a squashed Coca-Cola can with a snail on it, and a long piece of orange string.
The northeast corner of the field is highest and the southwest corner is lowest (I had a compass because we were going on holiday and I wanted to know where Swindon was when we were in France) and the field is folded
downward slightly along the line between these two corners so that the northwest and southeast corners are slightly lower than they would be if the field was an inclined plane.
I can see three different types of grass and two colors of flowers in the grass.
The cows are mostly facing uphill.
And there were 31 more things in this list of things I noticed but Siobhan said I didn't need to write them down. And it means that it is very tiring if I am in a new place.

The book is written entirely in the main character's (autistic) voice and is an incredible piece of narrative, in addition to being a moving story of life in the world of autism. There isn't a single line that isn't note-perfect, and I would have read it several more times if there hadn't been a enormous waiting list for it at the library.

The other books I've read seem to be part of a quad or triad on aging, the mind and memory, with The Bonesetter's Daughter being much more a story of Alzheimer's than of traditional medicine, perhaps waiting for me to finally get around to reading Elegy for Iris to complete the set. The jewel-like Long for This World seems to demand reading The Confessions of Max Tivoli so that I can set Henry (Michael Byers' quiet geneticist - caring for patients whose racing genetic clocks push them such that they reach senility before their peers even reach puberty) against Max, who in Andrew Greer's novel, grows physically younger & younger in appearance even as his mind ages normally. I seem to be on a little love affair with 1st person narratives and disease themed dyads for the moment (Geek Love / Mendel's Dwarf being a dramatic one), but it is really enjoyable to 'meet' so many people through these books, especially since, thanks to impending Board Study isolation, I won't be likely to meet many real ones in the near future.

The gays, plus autism and average essays

2005-03-05T20:16:00.000-05:00

Medical school is tripping merrily along as usual - last week was insane, as not only was it AIDS week at my school, I was also on the slate to do the ever-popular 'Hello! I am a BIG GAY HOMO Med Student! Let us talk about BIG GAY HOMO healthcare!' talk, which, these days I don't even really have to prep for, as it consists mostly of:

The gays, the transfolk, the big old dykes, they are not that scary. For example, they will not bite you if you seem nervous - they might even like you if you have the guts to admit that you are new, but will do your best, and that they should correct you if mistakes are made.
Sexual orientation is a useless piece of information in the medical setting, by & large. You need to know how, when, and with whom they have sex, and how, when and with whom they have emotionally supportive relationships, and the what, how, and when of their gender. This may or may not have anything to do with a) how they look, b) how they sound, c) what they call themselves. Me telling you that I have a monogomous relationship of two and a half years with another woman tells you a lot more about me than my so-called 'sexual orientation' of lezzzbian, which might mean that I sleep with men, women, both, or no-one, in varying combinations, time-courses & nmumbers.
That said, the gays, the transfolk, the big old dykes, they have some BIG HONKING health disparities that you might want to address - and you might know you should address them by the label people give themselves.
If during the proecess of applying this advice you aren't sure, or you think you misunderstood, ask. But only ask if you are sure that you can hear the answer without making some wierd, puritanical, sour grape expression, because that deosn't help anyone.
Treat all your patients, no matter what you feel about them as people, with dignity and respect.

As for the 50-books quest, it also trots merrily along: books 6 & 7 were disappointing, and fabulous respectively. A quick refresher list and mini-discussion before heading back to studying Neuro:
6. 2004's Best Science Writing - Ed. Dava Sobel
7. The Curious Incident of The Dog in the nighttime - Mark Haddon

The former was disappointing to me mostly because of the preponderance of space essays - there were exceptions to the blah-ness of these (especially the profile of an awesome female physicist doing very cool things with gobs of mineral oil and mystery particles), but even the biological science essays to which I am prejudiced lacked a certain spark to them. One of the dangers of best-of anthologies, in my experience, is getting just the bland, white-bread sorts of essays that probably would wear kahki pants and participate in student government associations, were essays capable of such things.

The latter was incredible - the time I spent reading it was worth 1,000 times the hours I spent in class listening to someone who has never even seen an autistic child drone on about Autism, Aspbergers and Conduct Disorder as if they were the items in a grocery list. Full discussion and dissection of the psycho-medical aspects of it will have to wait, however, as my Neuro syllabus and fast-approacing exam call.

Drowning in the brain

2005-02-15T15:32:00.000-05:00

Hey all - not dead yet, though not for lack of trying on the part of my neurology professors, who are doing their best to make sure that this course lives up to the med school trop of classes that rbing to mind trying to drink from a firehose. I have managed to sneak in one non-school book: Out, by Natsuo Kirino, translated by Stephen Snyder, marking the 10% goal in the 50 book meme. Unfortunately for the purpose of writing here, it didn't have anything in it that I can remotely link to medicine, but it was a really engaging film noir-ish novel describing the fallout from a young woman's murder of her husband and the coverup that she and her 3 female co-workers at a box-lunch factory come up with. It was a very interesting insight into the anti-feminist sensibility that irredemably marred the experience of living in Japan for at least one colleague of mine. A brutal rape late within the book is a bit too clearly evoked for comfort, and some people who haven't survived anatomy lab might find the scenes of 'disposal' of the bodies gruesome, but overall it was a tight, fast read. The fast part was really important, because in the days leading up to yesterday's exam, the only books on by bedside table were my neuroanatomy atlas and textbook, both of which I highly reccomend to anyone dealing with insomnia.
Next up to read is a collection of 2004's Best Science Writing, which has at least a couple essays that deal directly with neurology and the exalted scientists within the discipline who, in addition to discovering amazing things, sometimes also turn out to be... well, a bit off (e.g. Dr. Honeydew's story at Push Fluids about suspicious circumstances surrounding Pierre Paul Broca's aquisition of the big hunk of damaged grey matter that made him famous). I'm looking forward to finding out what Brown-Séquard thought he was up to with all those puppy testicles, how to talk to people who are completely 'locked in' as well as why Harvahd pays handsome salaries to folks on both sides of the alien abduction debates. In non-neuro topics, I think Atul Gawande's profile of the surgeon Francis Daniels Moore, and an investigation into drug-resistant TB should both be good reads. When I checked this out of the library I was under the impression it was the collection that a friend had sold me about which has an apparently hysterical article from Scientific American about Toxoplasmosis, but that was apparently a copycat one with a similar name. If I mamage to track the latter down at the library, I'll be sure to tell you how someone managed to make Toxo snicker-on-the-bus funny.

2005-01-27T15:57:00.000-05:00

The Dwarf Francisco Lezcano, Called "El Nino de Vallecas" - Diego Velásquez

On to Mendel's Dwarf, the 4th in my quest to read 50 books by Dec 31, 2005.

Mendel's Dwarf was an entirely different species of novel than Heart Seizure. The writing in Bill Fitzhugh's book is often laugh-out loud funny, but his screenwriter background tends to mean that the dialogue is punchy, declarative, and disinclined to erudition. The protagonist in Mendel's Dwarf is the opposite, unbearably brilliant, impeccably turned out in every way... except for the way that he has no control over, the autosomal dominant single nucleotide change that has left him "squat and bowed" at the level of everyone else's' knees, including those of the librarian named, of course, Jean, for whom he nurses an unrequited love. Dr. Benedict Lambert is incredibly likeable, and even when he is at his prickliest, horniest or most vengeful (excerpt), you find yourself rooting for him, which makes the end of the novel even more shocking. From a scientific point of view, the novel is delightful, peppered with footnotes detailing the genetic basis for various characters physiognomy and personality as well as citations from PubMed that, if read, are listed with mordant intent, and sly wit. This latter also appears in the naming of the characters, as we not only have a Jean, but also a Jones and Dawkins, who are Benefict's childhood classmates and are admonished in front of everyone: "Stop talking , Dawkins," snaps their biology teacher. "You never stop talking, boy, and you never have anything worth saying."

From the point of view of the writing, it even outshines the fantastic attention that Simon Mawer took with the scientific aspects of the novel, weaving a parallel structure of Mendel's life (ostensibly included because Dr. Lambert is Mendel's great-great-great grandnephew), Dr. Lambert's search for the gene that made him as he is, while using both to ask questions not just of genetics, but of the links between genetics and eugenics, the nature of medical ethics where they abut the issues of reproductive choice and modern technology, and most of all, the ways that all of us may one day be considered genetic dwarfs, and thereby feel all the more acutely the tragedy of Benedict's human search for love.

The excerpt that I decided to pull from this incredible novel is only slightly related to my current class, but I'll pull the quote to inspire my studies for my next class. It's enough to make me wish that our lecturers had any measure of Simon Mawer's way with words.

A scented cave, a dwarf's cavern dripping with stalactites and running with hidden rivulets and concealing somewhere deep within its declivities sparkling treasure -- glittering jeweled eggs, something from the workshop of a cosmic Fabergé, something fabulous and priceless, something lost to human knowledge. It lies there convoluted and burgeoning, folding itself into fantastic shapes, coiling and infloding, metamorphosing and changing. A sea-change into something rich and strange. Those are eyes that were mere pearls. Coral is become bone...
There are still moments in the manipulation of man or molecule where you are powerless. You splice a gene into a bacterium, transfer it to culture medium... and you wait. You transfect a mouse embryo with human DNA and watch, breathless, to see what happens. You spit two glistening embryos through a catheter tube into a receptive womb... and wait, listening. Human chorionic gonadotrophin, a 25-kilodalton glycoprotien hormone, is the first cry a budding infant makes, a tiny molecular cry for recognition, admid the roaring and screaming of the mother's blood. You sample at day fourteen, listening for that cry, sniffing with antibodies for that infinitesimal scent. Like a dragon, you can smell treasure.
Link

Deep in the land of Neuro, I surface briefly

2005-01-26T14:22:00.000-05:00

I finished both Heart Seizure and Mendel's Dwarf this weekend, as a fortuitously heavy snow brought bustling med school life to a slowed pace and let me spend a delicious Saturday afternoon snuggled in my hammock with blankets and good books.

Heart Seizure was decidedly the lighter of the two, as Bill Fitzhugh, while a dedicated and brilliant satirist, has never made any claims to being a deep writer, even though his themes often deal with thorny issues, many of them healthcare related. While closer thematically to his earlier book Organ Grinders (xenografts and medical ethics galore), the tone was more reminiscent of his first book Pest Control, from the biting, but never heavy-handed political satire (the poor fictitious prez takes some body blows) down to the gruesome and hilarious deaths that several main characters end up succumbing to. In order to keep this blog from becoming one big Amazon review, I'm going to try to target my reading to books that can reasonably be expected to contain content related to my 2nd year coursework, which is at the moment, Neurology and Neuroanatomy, and was, just prior to this, Endocrine. Heart Seizure had almost enough to let me pretend I was studying...

When one is about to be set upon by a man intent on cutting one's heart out with a knife, absence of fear is not an option. Extreme anxiety is inescapable. It is innate, stemming from the function of an almond-shaped mass rooted deep in the brain. Like a sponge squeezed by fear, the amygdala weeps a substance into the limbic system, triggering the physiological response that helped move Homo Sapiens up the food chain. Fight or flight. It is fixed in the geens, out of one's control. A downhill racer without brakes or steering. This amygdalic secretion triggers the adrenal glands to dischage glucocorticoids, compromising the immune system and escalating blood pressure. Heart and breathing rates rise, blood thickens. increasing the likelihood of stroke or heart attck, none of which is conducive to being put under general anesthesia, which is, of course, preferred when one is about to be set upon by a man intent on cutting one's heart out with a knife before replacing it with another.
Link

I'm running out of time, so I will have to deal with the incredible Mendel's Dwarf tomorrow. To hold you over, here are links to my two other favorite pieces of work featuring achondroplasiac characters, a list to which I have now added Simon Mawer's marvelous and wrenching novel.
To watch: The Station Agent, with Peter Dinklage
To read: Geek Love, by Katherine Dunn

A very selfish beginning

2005-01-21T19:03:00.000-05:00

I should admit, before we go any further, that I am beginning this experiment in writing more for me than for you. Medical school thus far has been doing a singularly good job of removing from my life the twin joys of reading and writing anything other than the journals, textbooks and syllabi that make up the day-to-day. So, starting this year, I vowed to myself that I would write more, and use this forum to embarrass myself into doing so. And when casting about for a way to embarrass myself into reading more, I came across this meme and couldn't resist the round numbers and flashy stars (50 books! All within 2005! Neal Pollack is doin' it!).
When I read fiction, a lot of it is medical or pseudo-medical, so I will hopefully be earning my medical blogger cred there, at least in snippets, and in between books will do my best to regale myself (and very likely only myself) with tales from my daily life from which I will cull the über-medical high points for presentation and dissection here. Now on to the books!
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For those of you that don't know, the life of a 2nd year med student is hardly the stuff of which action-packed blogs are made. We study. Thaaaaat's it. It's not even remotely riveting most of the time, but is utterly necessary. Because of this, the guilt that people have when they don't study? Well, let's just say that it rivals anything I saw my Jewish bubbe dish out even on her best day.

All of this is to say that the short story is the best friend of the guilt-wracked medical student who feels like an utter slacker for even contemplating nodding off to a novel rather than the New England Journal of Medicine. Appropriately, my first book of the 50 for this year is a collection of short stories by a writer whose telling of one of her less-compelling stories on NPR kept me in the car after returning home for nearly a quarter hour, just so I could hear the end.

1. The Girl in the Flammable Skirt, by Aimee Bender is a collection of 16 short tales with a thoroughly surrealistic and sexual bent to them. They are also fantastically tightly written and impossible to put down. All of her characters are broken in some way, with missing lips, mysterious lacunae through their middles, marvelous prostheses to add deformities or take them away. My favorites of the 16 were 'Drunken Mimi' featuring a sub-rosa imp and mermaid in high school and in love, as well as 'The Healer' which has a deliciously mordant main character whose unique nature has her healing people at the local hospital with a small smile that doesn't reach eyes.

2. Ella Minnow Pea, by Mark Dunn is a recommendation from my father, who is directly responsible for my love of language, and loves recommending books like this 'progressively lipogrammatic epistolary fable' which charmed the tatty scrub pants right off of me in it's cheerfully clever yet heartbreaking satire of the dangers of censorship and the joys of language. Told in letters exchanged between the eponymous Ella and her other family members, living on the independent island nation of Nollop, founded by the creator of 'The quick brown fox jumps over the lazy dog." But when letters start falling off the statue that bears this sentence on it, and this is interpreted as a sign that the deity-like Nollop wishes all use of these letters to stop, Ella and her family end up struggling to survive without letter after letter. You wouldn't think a book about letters (in both senses) would be so gripping, but I tore through it, and enjoyed every second.

Up next on the reading docket are:

Heart Seizure, by Bill Fitzhugh - a satire about politics and the current health care system. I loved Organ Grinders which tackled the tentacles that intertwine big medicine and big business to soda-sprayingly funny ends, so I'm hoping this one lives up.
Mendel's Dwarf, by Simon Mawer - I know nothing about this other than that it follows the drive by an achondroplastic great-great-grand-nephew of Gregor Mendel to find the gene that has made him as he is, and that my favorite librarian (one of the very few I trust to offer up quality for my precious reading hours) recommended it.