Why this summer may determine what I will do for the rest of my life

Today Dr. Karen Zier gave us a talk on research opportunities we may have for next summer, which is essentially the only intended period of time that we will have "off" from class between now and when we graduate in 2009. Her talk wasn't enlightening, exactly; instead, all it managed to do was make me more nervous about my plans for this year and my medical career. The point to my post a few weeks ago on choosing a specialty (see here) was to address this very topic. In that post, I somewhat flippantly took a look at all the fields of medicine in an attempt narrow down my medical interests by exclusion of fields I am definitely not interested in. The problem is that while there are some fields I am fairly sure I would never want to pursue (i.e. colorectal surgery), I really don't know anything about most of the fields of medicine, and therefore I can't determine my level of interest either way with any type of certainty. The conundrum that I am faced with (and that all medical students face, for that matter) is that while this coming summer is a great opportunity for me to do something interesting and important for my medical career, I really won't be getting any real exposure to medicine and patient care (outside of EHHOP and the other weekend clinics) until my third or even fourth years in school. By that point I will be expected to have singled myself out from every other applicant to the limited residency programs around the country, which means that I have to get started on that now. It doesn't seem worth it, though, to just get involved in geriatrics research for research's sake, especially when my ultimate goal might be a pulmonology residency. In fact, in my mind that may even seem detrimental on my record.

Dr. Zier said that many students who are not competitive enough take a year for "scholarly absence" between their second and third years (this notion, unfortunately, was corroborated by a fourth year I spoke to who is taking a year off to do ENT research so he can apply to the best residency programs). I would really rather not have to follow in that plan just to be placed in a good residency program, because the prospect of not graduating from medical school until 2010 sounds incredibly scary.

On the one hand, I really do not feel like I need to stress because residency seems like such a far off endeavor. On the other hand, however, I feel like I am already inexcusably behind for not having already shadowed a vascular surgeon, or not having published six articles on a new radiographic imagine technique I invented. I know that my primary interests seem to fit with global and community medicine, especially as they have to do with infectious disease, internal medicine, ophthalmology, immunology, or pulmonology. I also understand that I cannot spend the rest of my life traipsing around the world from clinic to clinic trying to treat all the poor people in the world-- I am going to want, sometime in the near future, a single place to settle down, financial stability and job security in a healthy and expanding medical field. I know that even a few years ago I had sworn off ever seeing patients (my plans were to go directly into research or public health administration after medical school without doing a residency program), but, at least at this moment, I envision a component of my career always involving patient care. I can see myself following in the footsteps of someone like Paul Farmer, who seems to actually be making a difference while still being a doctor and practicing medicine. The problem is that people like him are few and far between, and there is no clear path one can follow to get there (in fact, it seems that those types of doctors tend to reject being boxed into a certain mold, and come from many different aspects of medicine).

At this point I really can't see myself going into a surgical specialty. Really, though, most of these specialties are no more than just words to me, and I don't have any idea of what they really consist of. This is why I have been so adamant to volunteer at EHHOP, and I have started sending some emails to people about possible shadowing opportunities. I know that in the long run I will get a chance to experience all of these specialties, but I hate the feeling that I am falling behind and will not be competitive enough the do the things I want to do when the time comes. For example, Brigham and Women's Hospital in Boston is one of few hospitals that has a residency program in Global Health. I don't know if the program is really something that would interest me in the long run, but the thought of applying to BWH seems like such a long shot that I need to really start getting my act together now to even have a shot.

By the way, today is Halloween, so trick or treat!

How I spend my time

Besides for classtime and studying, I've been slowly getting involved in a number of the student groups that they have at Sinai. I thought that I would write them down to get a sense of how I have been spending my time.

I have been spending the most of my "extracurricular" time with Medical Students Making Impacts (MSMI), which is essentially the first-year trip to Belize. I have a feeling that that, along with the Medical Spanish class/elective, will take up most of my free time.

I have also been getting involved in Students for Equal Opportunity in Medicine (SEOM), the Ophthomology Interest Group and the Geriatrics Interest Group, the East Harlem Health Outreach Program (EHHOP) and the Ita Ford Clinic, the American Medical Student Association (AMSA), and the Comunity Health and Health Policy Group. I am not sure how involved I will be in all of these groups, though I have a feeling that for some if may not be more than attending a meeting or two every once in a while. I would like to limit my involvement in comparison to what I did at Columbia, where I took on leadership positions in two of the big organizations on campus. I want to make sure that I don't spread myself too thin. Although other healthcare and medical issues are extremely important, medical school probably merits that I focus most of my time on my schoolwork.

Everyday Medical Consult

Last night Stacey called me to ask for some medical advice on behalf of her friend. Her friend had been experiencing sudden sharp pain down her left arm and forearm, and her fingers started to go numb. She thought she was having a heart attack, so she went to the ER, where they did an EKG which showed normal heart function (and so her pain wasn't due to an MI). They also did CT scans axilla through her neck, but instead of explaining the results of the test, they gave them to her written on a piece of paper. She was calling me to ask for help in deciphering what it was that the piece of paper said.

The CT scan reported that she had soft-tissue swelling posterior to her left sternocleidomastoid muscle along with an enlarged lymph node (8mm) in her neck. They also reported that the pain might have been caused from a pinched nerve. The numbness had been in all her fingers, so that led me to believe that the source of the pinched nerve was proximal to the brachial plexus (and not somewhere along the radial, median, or ulnar nerves), and so swelling in the neck around the area of the C5 to C8 rami seemed like a plausible cause for her pain. I told her that she didn't have to worry too much about the enlarged lymph node (even though the node is roughly double in size, lymph nodes can get enlarged from many things), but that nerve problems don't tend to go away on their own, and that if the pinched nerve wasn't treated it could potentially get worse. I suggested that she go see a neurologist to determine the location of her nerve damage.

The interesting thing about this is twofold: first, that Stacey thought to call me to ask about this medical problem, especially since I've only been in school for some 3 months. And secondly, because of my Anatomy lectures and dissections in the past week, I was able to give a half-way decent response to her questions. I guess there is no better example of the direct usefulness of Anatomy and the medical education in general that this little anecdote. I came away from the conversation with a great deal of satisfaction that what I am doing is actually important. Of course I am not a doctor yet, nor did I presume to be when I was talking to Stacey's friend, but it was greatly satisfying to know something about what she was asking about.

Medicine on the Front Lines

Dr. Laitman introduced the lecturer today by saying, "As you all very well know, this country is at war. Because of this, it is important for you to know what medicine is like on the front lines." The lecturer was Dr. Kasulke, the Deputy Surgeon General of the US Army. He went on to give a very blunt, somewhat grusome, and not-candy-coated lecture on the weapons the Army uses to kill people (i.e. M16 rifles, landmines, etc), and what the weapons do to the human body. In some regards Dr. Kasulke was very frank and non-judgemental about war: he made no comments about whether war is right or wrong, whether we should be sending 18-year-olds to imminent danger or not, whether we have any right to invade sovereign countries. I was struck by how he viewed his position as no more than a job, not unlike any other physician in any other hospital-- although, justifiably more intense in his case.

He also made the deliberate point that the Army Medical Corps treated soldiers of all countries alike, be them American, British, Afgani, or Iraqi. He went on to say that in the case of medical triage, if two soldiers were brought to the medical camp, an American with a superficial bullet wound to his arm, and an Afgani with multiple bullet and shrapnel wounds to his torso, the Afgani would be treated before the American soldier. In other words, the American Army sends kids over to Iraq and Afganistan with the expressed purpose of eliminating the insurgent opposition, but if they don't manage to kill the "enemy" (as Dr. Kasulke referred to them a couple of times), then the Army sought them out and treated them, possibly even before their own casualties. Does that not send a conflicting message? Why do we send soldiers there in the first place, if we're just going to treat the wounded soldiers that the American troops attack? As an American soldier, I would probably find that to be a conflict of interest.

I think it is important to be prepared for all medical situations that can come up around the world. This lecture, however, just gave me a sense of the futility of it all. It's hard to feel good about attempting to do something good for people and even society, when it seems that more often than not we so easily regress and lose years of progress and advancement in the blink of an eye.

To Orangewalk (Part 1)

This is the first of what I am sure will be many posts about the Mt. Sinai first-year student trip to Belize that will take place next April. Somehow, I ended up as the coordinator for one of the two sites that students will be going to, though I have a feeling that I may yet regret the decision to take on that role. I know that it will take quite a bit of work to coordinate the trip, but I'm hoping that since a good portion of the planning legwork has already been done by the now-second-year students who went to Belize last year, I will be able to build off of what they did.

The trip itself sounds like it can be really interesting: it will be roughly 5 days of a mix of rural medical experience working in local clinics around the city of Orangewalk in the northwest of Belize along with public health education in local schools. At today's information session, roughly 45 first-year students showed up and said they were interested in going on the trip, which is wonderful considering that the entire class is only about 125 students. We're hoping to whittle that number down to about 30 students by the end of next week, half of which would be going to Orangewalk and the other half would be going to a city in the southwest called San Ignacio.

I'm excited about the trip, and I think it will be a great experience. I'm in charge of the data collection and epidemiology component of the trip, that will hopefully be used to modify how subsequent trips are organized by future Sinai students.

Ita Ford, 23 Apr 1940 – 2 Dec 1980

After a long, tiresome week full of anatomy dissection and long classes and extracurricular activities, it was my turn to work a Saturday at the Ita Ford Clinic on 115th St. and 1st. Ave. On my way over there in the cold wind and rain I was half regretting having chosen this weekend to work at the clinic, but it wasn't something I could really get out of, and plus, I knew that I was interested in the experience. I had a great experience there though, and I am really glad I went.

Ita Ford works a little differently than EHHOP: firstly, only three first-years and one upperclassman work the clinic, even though they see about the same number of patients that EHHOP does (about 12 per day). There are two nurse practicioners that run Ita Ford, and no physicians. It is also done in the middle of a church office, with no privacy and no medical equipment except for what the NPs bring with them. All in all, it has a much small, more community-based feel to it than EHHOP does, which is run out of an actual Internal Medicine office. I can't say which one I liked better than the other, though: while I think EHHOP is far better equiped to deal with medical issues, Ita Ford seems to be a little bit more about the patients and less about the medical student experience.

With six people working Ita Ford this weekend, I was pretty much the only one who had any type of working knowledge of Spanish. While I hardly know how to conduct a medical history in English, let alone Spanish (i.e. I have no idea how to say gall bladder in Spanish), I was runing around trying to translate for everyone trying to figure out whey the patients weren't feeling well. With Colleen (ne of the NPs), I personally saw two women needing prescription refills, one woman needing a checkup, one man with diabetes who works at a French bakery (bad news), and one woman who suffers from depression and what looked like hepatomegaly (though we were waiting on her liver function tests to be sure). It was very interesting, and I got a chance to take blood pressures and things like that.

The Ita Ford Clinic normally receives most of its medications through a program they worked out with Bristol-Myers Squibb. Recently, however, BMS has changed its policy of drug donations, claiming that drugs can only be given to U.S. citizens. Since almost 90% of all the patients at Ita Ford are immigrants, this new policy has practically wiped out Ita Ford's ability to give drugs to its patients. This has become a major issue, as highlighted by the first patient whom I saw on Saturday, who had eight medications she needed to refill, each of which was upwards of $100. Since Ita Ford has a meager budget of about $3000 per month for prescriptions, this one patient was going to account for a large portion of that budget if the clinic paid for her medications. It is just very sad that in the meantime while the clinic staff works on how to obtain drugs cheaply, it has to turn patients away who are not able to pay for their own medications. It is just an incredibly horrible situation.

Before I get back to my reading, I wanted to talk a little bit about Ita Ford, the person, as opposed to the clinic that was named after her. She was a nun who worked for many years in El Salvador looking after the poor, and was raped and killed along with three other nuns in December of 1980 by member of the El Salvadorian National Guard. One on Ita Ford's nieces is the NP who started the Ita Ford Clinic here in East Harlem. Ita's story really struck a cord with me in relation to the clinic and her selfless work with the poor community. I just hope that I am able to think about some of that as I progess in this field I am working in.

"Some things hold true wherever one is, and at whatever age. What I’m saying is that I hope you can come to find that which gives life a deep meaning for you, something that energizes you, enthuses you, enables you to keep moving ahead. I can’t tell you what it might be. That’s for you to find, to choose, to love. I can just encourage you to start looking and support you in the search."
-- Ita Ford

Going in for a Checkup

I think it is worth it to do a checkup of what medical school has been like thus far for me: in 10 weeks I have had 2 midterms (M&C and Anatomy), 2 final exams (Emergency Med and Embryo), a couple of interesting clinical correlates (Krohn's, CF, sickle cell, ALS...), two patients (through EHHOP), and of course, lots of class time spent in Annenberg 12-01 and in the Gross Anatomy lab. As trite as this may sound, I do consider it a moral victory to have not only survived my Anatomy midterm, but to have beaten the curve set by the class. I would have to say that if there is any single class that exemplifies what people think medical school is about, that class would be Gross Anatomy. So it is satisfying to do well on an exam that is thought to be the epitome of medical school. It is also satisfying to do well after having done so poorly in my Anatomy of the Lower Extremities course at Duke, especially on the practical exam (that always left a bitter taste in my mouth...). The range on the midterm was from 53 to 95, mean was 83. I scored an 86.3, which is well within one standard deviation (=7.2), but good enough to put me in the top half. In total, 21 out of 125 students received either failing or marginal grades on the exam. A 53 is going to be a hard score to recuperate from (he or she would need an 87 or better), but it's obviously not impossible. Another interesting point is that I did better on the practical than I did on the written, which was rather shocking: in the four practical exams I've taken (two in AotLE and two this summer in SEP), I've always done better in the written section, and I did far more studying for the written part of this particular exam than I did for the practical (the class average was almost two points higher for the written than it was for the practical).

I go into great detail on this exam not because I always want to remember what the range was on my Anatomy exam, but simply because it it's the first major exam I've taken (of course, this statement ignores the Embryo exam, which at the time seemed like a very big deal, as well as the first M&C midterm, which was annoying to study for but really wasn't all that bad), and being that it was given about 10 weeks into school, it is a good benchmark to see how the adjusting process has been going. On the whole I am generally content with the way it is going: while I never had any doubt about whether I should have been accepted to medical school or whether I wanted to be here in the first place, it is a little comforting to be proven somewhat right. At least, for the time being, that is.

Yesterday we met with a patient who has been diagnosed with Marfan's Syndrome (disease manifests as tall stature, disproportioned features, weak blood vessels esp. aorta-- this was the disease that Jonathan Larson, the writer of the musical Rent died from). He was a very interesting, lively 45 year old man. Since being diagnosed in 1986, he has since become the chairman of the National Marfan Foundation, which is apparently doing great work as far as advocacy and education are concerned. I read an article in this month's Atlantic Monthly that talked about Abraham Lincoln and how he suffered from clinical depression, possibly had Marfan's, and was reported to have been gay. The article went on the say that if a candidate for president today was found to have these conditions, he would be instantly declared unfit for office. It is hard to justify this reasoning, however, when we consider how successful Lincoln was as president.

As part of the unofficial "Medical Spanish Elective" that I am "taking" this semester, there was a screening of the film Mar Adentro (The Sea Inside) tonight. It's a Spanish movie about a quadriplegic man who wants the legal right to end his life, because he would rather die with dignity than life in the state he was in. Incredibly, incredibly sad movie, but quite well done, I thought. Nothing special, but a compelling and moving storyline. It was set in Galicia, where my great grandfather was from, and the views of the sea were very pretty. Not a date movie though.

The last thing I wanted to write about was the CMCA Open House I attended this past Sunday. They asked me to be on a panel of minority medical students to answer questions from high school and college students about medical school in general and Sinai in particular. It was very interesting to be on the other side of the table, so to speak, especially since I had been sitting in the exact seats those students were in less than a year ago, asking the same questions and voicing the same concerns about which medical school to go to, and about whether I would be accepted at all. Since I have only been here for the past few months, I thought that I wasn't going to have anything to say, but apparently not: with each question they asked, I found that I had thought a lot about each of their concerns, and actually had to stop myself from dominating the panel. I am really glad I did the panel though; I think it's incredibly important to motivate other minority students to apply to medical school, and give them suggestions as to how they can be competitive applicants.

I think I have said a mouthful tonight. Tomorrow is the last day of Behavioral, and then ASM small groups. I am also going to try to make it to a few interest group meetings if I can.

So Long Zygapophyseal!

So now that yesterday is over (yesterday being the day of the Anatomy midterm exam), I can officially move on with my life. It's quite amazing how students can convince themselves that these exams are the most important things in the world, and that while just about anything can happen around them (like hurricanes, earthquakes, tsunamis, wars... literally), in that moment, nothing is possibly more important than the root value of the lateral femoral cutaneous nerve of the thigh. I find it to be incredibly sad, personally. I think that is one of the reasons I am so starved for the New Yorker or the Economist at the beginning of every week. Honestly I don't know if the way the subject is taught in school is wrong-- I just think it could be a bit more balanced. I think students wouldn't be half as stressed if they realized that other things were going on around them-- and in the long run, the relevance of the semispinalis cervicis musle to our everyday lives is mininal.

I wanted to add something to my last post about specialties: while the list of specialties I used certainly covered a number of the fields of medicine, it certainly was not exhaustive. After I sent the post I thought of a few other specialties I am interested in, including infectious disease and pulmonology. I have professors in both of those two fields, and I was thinking that if I got my act together, I'd like to see if I could shadow them or at least talk to them about what the field really entails.

I also wanted to mention a neat program that Sinai's Global Health Center is putting together, and that is a Global Health Fellowship program. It is for doctors after their residencies, and I think it could be right up my alley. I could definitely see myself doing a residency in internal medicine and then a fellowship in global health. Food for thought.

Today is Stacey's birthday. We have plans of going out to a bar with 50 of her closest friends. It's also pouring rain and 50 degrees outside. Gross day for birthday plans. I guess that's not something we can do anything about. I hope she has a really good time tonight.

Let's play the "Choosing a Specialty" Game! (Part 1)

So for a lack of a better time to do this, I figured I'd start the first round of the Choosing a Specialty game today, even though I am a first-year and have no business picking a specialty. This is more to see how things might change over the course of the next few years, and whether the place I'll end up is where I'd imagine I would be. From a list of specialties, I ranked them from 1 (absolutely no way I could do that) to 5 (I could definitely see myself doing that). So... here goes:

5 Allergy and Immunology
4 Anesthesiology
1 Colon and Rectal Surgery
3 Dermatology
3 Emergency Medicine
3 Family Medicine
4 Internal Medicine
2 Medical Genetics
2 Neurological Surgery
2 Neurology
4 Nuclear Medicine
2 Obstetrics and Gynecology
5 Ophthalmology
3 Orthopaedic Surgery
4 Otolaryngology
4 Pathology
2 Pediatrics
2 Physical Medicine and Rehabilitation
2 Plastic Surgery
4 Preventive Medicine
3 Psychiatry
4 Radiology
3 Surgery
2 Thoracic Surgery
1 Urology

So to recap, the only specialties that I gave 5's to are Allergy/Immuno and Ophthalmology. Quite a numbers of 4's though. And of course, I may just have no idea what I'm talking about. I guess I have a lot of time to think about it.

Before Anatomy

It's two days before the anatomy midterm exam, and I'm looking out of the Levy Library windows over Manhattan on a excessively cloudy day when everything looks dull and white. At least days like this make me not feel so bad about being inside all day-- this is how it should be before every major exam.

I walk around Sinai and everyone is scurrying around me with nothing on their minds except the exam and how much more studying they have to do-- I really don't know why everyone is so stressed (it's even starting to stress me out just by being around them). Most of the people will do fine on the exam (most know this subject far better than I do). I think they are just making this a much bigger deal in their minds than it really is: it's an exam like any other, no bigger than an Orgo midterm or final, certainly less important than something like the MCATs. I think this exam, more so than the other exams we've already taken since we've been here, represents for them the essence of being in medical school, something they have spent so many years thinking about and trying to attain. I guess they just need to let it out of their system. I also think it doesn't do them any favors to freak out about something that is much easier to deal with when you are calm and collected.

I wanted to talk a little bit more about my patient at EHHOP yesterday before I get back to Rohen and Netter. I was thinking more about the advice we gave her, and more and more I think we did her a disservice. Essentially, we just gave her an antidepressant medication and sent her on her way, without giving her any other advice on how to deal with her problems and issues. When the senior clinician and I left the room he asked me if there was anything that I thought he had missed in taking her history, and I said that I thought we should have asked her about the other types of things that she was doing to deal with her stress, i.e. meditation, prayer, talking to someone like a counselor or friend, etc. In the end the attending did suggest that she think about going to an AA meeting because of her drinking problem (which had gotten much worse with the depression), but essentially we gave a person who has had a past history of addiction a drug to deal with her stress and anxiety issues-- a drug that she can become dependant on just like the alcohol. I would have felt much more comfortable giving her numbers to call of people that specialize in alcohol addiction, and suggesting she see a psychiatrist, and not just a social worker that would help her get insurance. I hope things end up being alright for her, but I think there was a lot more that we could have done for her.

But for now, I am resigned to focus my time with general visceral afferent fibers and referred pain.

EHHOP on a rainy Saturday

Based on the suggestion of a couple of people, I decided that now was the time for me to develop my very first blog. I have some down-time right now as greeter at EHHOP (it's a slow day because of the rain), and so I thought that now was as good a time as any to start writing down the experiences I have been having in medical school. I am already two months into my first year and a lot has already happened (so I'll be playing a little bit of catch-up), so the purpose of this blog is to document some of the events as I go through medical school at Mount Sinai School of Medicine. I am not normally a public person, especially as far as thoughts and feelings are concerned, so this is going to be treated as an experiment, at least for the first couple of months. I would really like to keep a running tab of the things that happen around me, so that I can take a look at it during the times when everything seems to be a blur. If everything goes well, I may want to put together blogs on other topics, such as travelling and photography... but I'm getting ahead of myself.

I guess the best place to start is with today: with a 4th year senior clinician I saw a 40 yr. old woman presenting with depression, caused originally by her high-stress job, and continued once she left the job and has been unable to find work. She had also been an alcoholic many years ago, and recently started to drink again, most likely because of her depression. We ordered a bunch of liver function labs and prescribed her Celexa, which she had taken before and had been working for her.

The experience was interesting because it highlighted how the history-taking process can be very difficult: for instance, when asked a straight-forward question such as "Have you had any surgeries?" the patient responded no, but it was only after reviewing her past medical records was it that we found out she had had breast implants.