medical school @ mssm

Orientation

2006-08-17T13:25:00.000-04:00

Today is the start of orientation for the new class of first-years at Mt. Sinai, and so an extra 120 well-dressed students are running around Annenberg today trying to fill out all their paperwork and get ready for classes to start. I think this officially makes me a second-year, because like it or not, I can no longer be a first-year student. For some reason I am not all that thrilled to have a younger group of students at Sinai-- I think I was finally getting used to my role here (as the bottom of the barrel), and faces had started to all look familiar. It's not so much that I look at the new students as competition, per se, but it's more of a realization that things are changing. I think I am also concerned that once second-year starts, things really won't slow down until after the match in 2009, which seems like an unbelievably daunting task.

The days getting shorter and shorter...

2006-08-08T16:18:00.000-04:00

I (*hopefully*) finished the data collecting phase of my summer research project, so today I'm able to stay at home and do some of the data analysis on my laptop. I just picked up an Orson Welles film, so that is playing in the background. It's definitely not as hot today as it was last week, but in my living room it's still on the warm side.

I have a meeting with Dr. Richardson tomorrow, I'm hoping that we'll get somewhere with the data analysis part of the project. I'm around for another two weeks before leaving for Toronto, and it would be great to be working on the manuscript by then. We'll see what happens-- while it's been a bit nice to work at my own pace, the project started slowly and now I have to play a bit of catch-up.

I was looking through the latest Time Out New York, and for some reason there didn't seem to be too many exciting things happening these days in New York. The SummerStage schedule wasn't very good this year and there weren't too many free events that caught my interest. I don't know, maybe I just didn't take advantage of all the things the city has to offer. I did get a chance to see Corteo and Macbeth at Shakespeare in the Park, and of course I took those trips to Brazil and to Germany for the World Cup (which was amazing). And I did move to my new apartment and started going to the gym regularly (we'll see how long that lasts) , but that's been about it. Over the last few weeks I have been spending some time with old Columbia friends, mainly because Anu is leaving for graduate school in Dallas in a few days, and we've been trying to catch up before she left.

Last Friday I shadowed Sigrid Hahn in the Sinai Emergency Department for a number of hours. She is great to shadow, because she explains things really well. I had the chance to take a few histories and present the patients to her. There was a lady having an acute stroke, two guys with heroin overdoses, and a few elderly patients with heat-related complaints. I had a really good time there; I wasn't used to juggling all the different patients at once, but I felt that I could do a reasonable job obtaining histories under those circumstances, and think about potential plans of action. I'm hoping to shadow a bit more during the year, but it'll all depend on how much time I will have to do that.

We got an email from Mt. Sinai today saying that our schedule for next semester is on Web-Ed already. That coupled with the fact that I just ordered all the textbooks I'm going to need (a paltry $600), these summer days seem to be drawing quickly to an end. On the one hand I'm a bit excited about moving on to the next step (first-year is only good enough to get your feet wet), but on the other hand... I am worried about what happens when the ball starts rolling-- it'll never stop.

Heat Wave

2006-06-20T11:20:00.000-04:00

I guess the time around final exams in not very conducive to finding time to write on this blog-- this semester in particular, with so many things going on at the same time: exams, birthday, moving to my new apartment, going to Brazil, starting my summer project... I'm in the East Building right now, trying to stay cool during this summer heat waver that we are having. I'm working on this health disparty project in the Emergency Dept. with Dr. Lynne Richardson, which began with a slow start, but is finally starting to pick up speed. I don't know how much will actually be done by the time unofficial deadline of August 13 (the day the project abstract is due), but we'll have to see. I know that at this point, I'm just going to have to put in some long hours to get the dataset completed on time.

I go back and forth as far as staying in New York is concerned. On the one hand I like being able to slowly put my new apartment together and lead a relatively relaxed lifestyle for a few weeks. Plus, it's not like I'm spending every moment in NYC this summer-- I spent a week in Brazil, a week in Germany for the World Cup (which was amazing, in spite of the fact that Brazil didn't make it to the semifinals), and I will be ging to Toronto/Montreal/Detroit at the end of August. Still, I get this sinking feeling that it would have been better to get away for a longer period so I could be a little more refreshed by the time school starts up again in September. It promises to be a tough year-- and a tough three years for that matter-- that I wish that I was spending a little less time inputting data into a computer and a little more time doing fun things. There are so many things happening in the city this summer, and I sort of regret not taking more advantage of them. I did go see the Shakespeare in the Park production of Macbeth with Liev Schreiber a few weeks ago, and last night I went to see the Philharmonic in the Park with a bunch of people from Sinai. It was nice, especially the fireworks at the end, but on the way home we got caught in a torrential summer downpour that left me drenched to the bone. I want to make sure I do more things like that though.

I also had all these big plans for finally putting together my photography website, which has been many years in the making. I don't know if it will actually make it off the ground since I'm still in the research phase, but I don't know when I might get a better chance. I've got about 4 weeks to figure all those things out.

I'm CMing this Saturday for the time time in months; I know I'm going to be rusty but I'm just hoping that I will remember all the things that I have to do. It'll be nice to get back into a clinical setting, since I haven't really had that chance with my summer project.

Farmer and the Pathologies of Power

2006-05-05T13:48:00.000-04:00

Yesterday I took part in a conference call with Dr. Paul Farmer through the AMSA Global Health Scholar Program. Just as he was when when we met last Friday, Paul was extremely warm and receptive to to us and our questions. Or conversation ran the gamut of global health issues, from his projects in Haiti and Rwanda, to the best ways to develop global health interventions, to how to galvanize national governments and multinational organizations, to questions surrounding human rights and morality, and much more. It was a wonderful conversation and it was such a priviledge that I had the opportunity to take part in it. I am debating on whether to contact him at some point, but I'm not sure if I would have the opportunity to work with him.

I have another interview next Wednesday with the TB Alliance. Hopefully I will be able to finalize some type of project with them for this summer. I am not sure how I'm going to juggle all the plans I have, but I would really like to have a global health component to my summer.

In other news, we just found out that one of the students in my medical school class passed away last week. We don't know what she had exactly, but we know there was a congenital disease that also took her mother's life. When her health problems worsened, Sarah took ths Spring semester off in order to rest. She passed away at her grandmother's house in Massachussetts. There was a memorial service for her yesterday at Mount Sinai, and a number of students and faculty who knew her spoke.

Yesterday we also found out that one of my roommates contracted tuberculosis. He had a positive PPD and so they did a chest xray, which also came back positive. Now they have to culture his sputum to see what strain it is, and then he will most likely be put on isoniazid and rifampin. It's pretty wild that something like that would happen, especially since he had a negative PPD last July. He's worried about it, and let his family know that they should also get a PPD test done.

A YEAR?!?!

2006-05-01T14:19:00.000-04:00

I just took my midterm exam in Pathogenesis and Mechanisms of Host Defense, which means that only three final exams stand between me and second-year (those being Path, ASM, and PMHD). As the end of first-year is quickly coming into sight and I can count the last assignments I still have to do on my fingers, I thought this would be a reasonable time to think about what has happened in the last 11 months. About a year ago I was putting the finishing touches on my Master's Thesis (I think it was due a year ago this Friday), and I was getting ready for graduation. That was such a crazy time, when I still didn't know where I would be going to medical school (NY... Miami... anywhere...). Soon after I accepted the spot at Sinai, I started the SEP program. While that program was a great practice for the actualy courses we'd be taking in the Fall, it was all still surreal to me. When classes actually started and we met all the rest of the students, things started to move really quickly. I remember the first time I volunteered at EHHOP I was scared to even touch the patient... now I almost feel like I could do the whole history/physical on my own (as I did countless times in Belize). This year I dissected two cadavers, got the opportunity to be an AMSA Global Health Scholar, spoke with Stephen Lewis, met Jeff Sachs and Paul Farmer, saw Bill Clinton speak, went to Belize, and am closing to having a paper published. It has truthfully been a roller-coaster ride, and I definitely would not have thought so much would happen in this year.

The End of AIDS: the CNN Special Summit with President Bill Clinton

2006-04-30T11:57:00.000-04:00

Saira and me with Paul Farmer

So last week Tina (the AMSA GAF) let us know about an opportunity to attend the CNN Presents Special Summit with Bill Clinton called The End of AIDS: A Global Summit (I'm not sure how long the website will be up, but for now it's here). It was being beld at the Mother Zion church in Harlem, and AMSA was given a bunch of seats in the audience. Since it was being held so close to where I live, I figured I couldn't pass up this opportunity. I skipped out of an Epi small group that I was supposed to run and went with a few other Sinai students. The show was set up as a conversation between Dr. Sanjay Gupta from CNN and Clinton, with thoughts from "panelists" interspersed in the conversation. The panelists included Dr. Helene Gayle of CARE, Bill Roedy of MTV International and the Global Media AIDS Alliance, activist and actor Richard Gere, Dr. Zeda Rosenberg of the International Campaign for Microbicides, Dr. Paul Farmer of Partners in Health, the Chairman of Pfizer drugs Hank McKinnell and the director of Doctors Without Borders. The focus of the program was the international span of the HIV/AIDS epidemic and it centered on a model of how to realize the goal of “a world without AIDS” in 20-30 years. It was very interesting to see how a show made for television is organized-- I haven't seen the final product on TV yet, but I'm really curious to see how they put it all together. At the end we had an opportunity to meet Paul Farmer and have our pictures taken (as you can see above). He was just the most friendly and approachable person... we're also going to be talking with him this coming Thursday. I am really excited.

What we learned in Belize

2006-04-16T00:01:00.000-04:00

At the Clinic in August Pine Ridge, April 11, 2006

I really don't know where to start with this post. The problem with writing all of this down now is that it is all in retrospect, and I'm afraid of losing some of the emotion that was felt during the whole experience. Suffice it to say, going to Belize was an amazing and inspiring experience of self-reflection and personal growth, and really solidified some of my beliefs, desires, and understanding of myself.

On the one hand, I am fully aware that the one week trip cost up to $70,000 not to mention hundreds of hours of collective time and effort put in by the students who went on the trip, and in the end, very little was actually done on a tangible level for the people we saw and treated in Belize. What they need is far more than what a group of 50 students and doctors from the U.S. can give in a week's time-- they need what everyone living in apparent poverty in developing countries need: economic and human development, access to care, and the education to take care of themselves and their communities. Still, all the interactions that I had with patients while we were there makes me believe that we made a contribution, even if it is no more than just a dent: the 2000 patients we treated both in Orange Walk and in San Ignacio responded to us with nothing but appreciation and thanks, giving me the impression that a.) they are in desperate need of some coherent health care system, and b.) every little bit helps. I don't think I am wrong about that. I left the trip feeling optimistic not only because it came off more or less without a hitch, but because I felt like there was an exchange, albeit skewed heavily in our favor.

Working in the clinics in Belize was everything that I live about medicine. The medicine was simple, and the intention was clear: to provide some care to people that would normally have a much harder time obtaining it. We weren't curing anyone of anything-- in fact, in general all we could do was alleviate some of the pain with over-the-counter drugs. I think on some level though, they also wanted us to hear their stories and try to be sympathetic.

Last week was the first experience I had had where I felt like I was actually "taking care" of people. I know that what I did wasn't much, but there was something about the history taking, brief physical exam, presentation to the physician, and dispensing of the medication that made me feel like I was involved in the whole process of treating people. And by the end of the week, I actually felt like I was actually able to diagnose most of the patients I spoke with, and had an idea of what to prescribe. I think this is nothing short of amazing considering all of my exposure to medical treatment is from EHHOP and from my ASM clinical sites.

More importantly though, I think this trip has helped me to make my own interests a little bit clearer. My experience in medical school thus far has been by and large to decide I am not interested in the fields that we are exposed to rather than to really enjoy them. There was a moment on the first day of clinic in Belize when I was walking from lunch back over to the clinic that I realized that I was really enjoying what I was doing, and that it was something that I could actually see myself doing in the future. That has happened very few times in my life.

In the end, I know I didn't cure anyone of what really ails them. But I did learn a little bit about myself. And I got to know some great people a bit better too. The people on the trip are some of my favorite in my medical school class, and it was really great to spend that week getting to know them. I have a feeling that we all had a shared experience that will make us closer.

CMing

2006-03-25T23:15:00.000-05:00

Going to take a quick break from studying physio to write a little bit about CMing at EHHOP today. It was my first experience being clinic manager, and I definitely felt unprepared for it when I got the phone on Thursday from Matt and Jeff. They explained to me all the things I had to do prior to the start of clinic on Saturday, and then what the day was generally going to be like. I called all the patients and got a little worried when I got in touch with less than half of them, but there wasn't much I could do about that. On Saturday morning, the two second-year CMs that were keeping an eye on me were really nice and did a great job of letting me run everything while making sure that I did all the things that I needed to do. There were a bunch of odd things that happened right off the bat (us having to use the Geri area instead of Medicine cause it was being painted, we couldn't find any of the files we needed because they were stored somewhere else, the websites were all down...) but we kind of went with the flow, and the teaching seniors were extremely helpful. I really enjoyed setting up the clinical teams and having them ask me questions about procedure or telling me about how they thought their cases were interesting. We had a little backup of patients around noon because we were waiting for Spanish-speaking seniors, but in the end I think it all worked out. Everyone got to see a patient, and most of the interviews went off without a hitch. I checked everyone out and closed up shop by 4:45, and was back by 5. It was also cool to spend some time with upperclassmen as they talked about second year, what sites to choose for third year, etc... It's good to get perspective from people outside of our first-year class once in a while. Now I have the EHHOP phone for the next two weeks because next weekend is the community health fair, but hopefully I won't run into any difficult cases. I think the next time I'm CMing I'll have a much better idea of how to direct people's questions (as opposed to having to confer with the teaching senior all the time to make sure I wasn't any wrong decisions).

Lack of Communication

2006-03-19T12:44:00.000-05:00

In an effort to make this blog more intellectual (and less a recounting of everything I do during the day), I thought I'd start responding to articles and news that are medically pertinent. The first one I want to talk about is a actually a blog entry by a Dr. Brent Ridge, who happens to be a geriatrician at Sinai. Here is the link to the blog itself, but in case it gets taken down at some point, I am including the text here (it's not too long):

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Do you ever leave the doctor's office feeling a little unsatisfied with the visit? Are you ever frustrated by a conversation you've just had with the doctor? Do you ever think the doctor was outright rude? You're not alone. In this blog, I thought I'd try to convey the doctor's perspective. Being a caregiver for a sick relative or loved one is a difficult and often thankless and unrewarding job. More and more, physicians are feeling the same way.

To our discredit, doctors do have the habit of doing more talking than listening. Unfortunately, this has only become worse as managed care has strictly curtailed the amount of time each patient has with his/her doctor. While doctors do try to spend as much time with their patients, this time pressure constantly forces doctors to ignore the patient's own emotional health. Truthfully, if the doctor actually spends any amount of time at all addressing issues of the caregiver's sanity and emotional well-being, you should count yourself as very lucky.

However, I can't place the blame for the lack of communication solely on the doctor. Let's face it-- we are all human. Patients (and their caregivers) are not perfect, and also contribute to the lack of communication. In one survey doctors rated 15% of their patients as "difficult." Disagreements involve everything from expecting an instant cure to demanding prescriptions.

Patient and caregiver qualities described as "frustrating" by doctors:

Do not trust or agree with the doctor. (You need to at least give your doctor the benefit of the doubt. After all, you are there for his/her advice.)
Present too many problems for one visit. (I understand you are trying to make the most out of your visit; however, please remember, there are 15 more patients waiting right behind you.)
Do not follow instructions (Again, you asking for your doctor's advice. What's the point if you don't follow his/her advice and instructions?)
Are demanding or controlling. (Doctors are there to work with you to stay healthy--- not work for you.)
Present themselves as overly helpless (You have to give your doctor some guidance in order for him/her to help you)
Make a melodrama out of every symptom (Yes, it is important to let your doctor know every symptom. However, over dramatizing each one can be counterproductive. If you do so, your doctor will not be able to gauge which symptom is more relevant in determining your illness)

Despite the common saying that the "squeaky wheel gets the grease", that's not how it tends to work with the doctor. Studies have shown that patients or families who make too many demands on the physician's time ultimately get less attention.

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I thought this was an interesting point that Dr. Ridge makes. We often hear reports of how doctors don't listen to their patients, about how doctors don't make decisions with the patient in mind, and how in general a visit to a doctor is an unpleasant experience. Dr. Ridge remnds us that the visit is really a two-way conversation between two people, each who has his or her own thoughts, ideas, prejudices, and expectations. It's only by really opening this dialogue that you are able to really have an effective doctor's visit. This, unfortunately, often gets lost, especially when physicians are under pressure to see as many patients as possible.

Saying goodbye

2006-03-15T02:01:00.000-05:00

I'm sitting at DT-UT having a cappuccino, taking it easy and enjoying the end of Histo. Stacey's in Uganda this week working on an AIDS orphan project, and I don't really have a lot of work to do for tomorrow, so this is the perfect chance for me to get out of the Mt. Sinai area and do something different (and yes, going down to 2nd Ave and 84th St IS doing something different, since it seems that whenever exam time comes, I don't ever leave the 3 block radius around Sinai). I would probably be up to doing something even more exciting tonight, except that I'm recovering from a cold that I've had for the last few days, and fifteen blocks is about as much as I can muster right now.

Tonight we had a closure ceremony of sorts for our Anatomy class... even though Anatomy ended three months ago, this was the first time that was available for us to reflect on the experience we had in Anatomy and say goodbye to the cadavers we worked on all last semester. About half the class showed up for it, and it was a very solemn experience, with a number of people having some very sincere words to say about what the experience meant to them. Some people read poems or read things they had written about the experience, and others just spoke about what came to them. I hadn't planned on speaking, but when we were asked if anyone had anything to say, I decided to make a few comments about what I thought Anatomy had meant to me. I spoke about a conversation that I had had with Eric towards the end of the Anatomy class, where he had said that throughout his life, he had always been alright with being ignorant about the things that were inside the human body. After Anatomy, though, I think we all have a different appreciation for what makes up the human body, and may never see a person in the same way again, which in itself is pretty significant. After everyone who wanted to speak had spoken, we went into the Anatomy Lab and lit some candles while Patrick played a piece on his clarinet. It was a rather emotional moment, and a number of people were crying, or at least trying to hold back tears. I thought it was a very fitting end to a course that was a very significant part of the medical school experience. Truth be told, I think I might not have thought enough about the whole cadaveric donation process and what it all meant to the people who donated their bodies and their families, but in the end I am very glad that we learned Anatomy in the way we did. Anything less "hands-on" would have taken away from the full experience.

Tomorrow is the last day at our first set of ASM clinical sites, which have been been a really enlightening experience. I think the things that we are attempting to learn in ASM are only truly learned through the experience of interacting with patients, and so I've really appreciated the time that we're spent with Dr. Serlin. I know that we'll have plenty of time to do all of this ad nauseum in future years, but I think it's really important to get a sense of why we are all going through this process, even at this point.

I am also meeting with Dr. Zier tomorrow, the person in charge of medical student research projects. I'm trying to work something out with a professor who is doing health disparity work in the ER, but she hasn't gotten back to me yet, and I am hoping that Dr. Zier can help me out with setting something up. At this point, I'm starting to feel like I don't want to deal with the stress of setting up some grandiose summer project; instead, I'd just like it all to be figured out already. There have been too many extraneous things to think about so far this semester.

Tomorrow night I'm having a conference call for the AMSA program with Stephen Lewis, the UN envoy on HIV/AIDS. He worked at the Earth Institute while I was there, and I saw him speak a number of times. He's an absolutely phenomenal speaker, and I'm excited about getting the chance to speak with him. The topic is on women's health and HIV, and I think he'll have a lot of interesting things to say.

Alright, I think it's time for me to be heading home. I've got some Belize emails to send, and I want to get ready for my meeting with Dr. Zier tomorrow.

What renal physiology, the global TB epidemic, and esophageal varices have in common

2006-03-08T11:01:00.000-05:00

Stumped? Well, I won't keep you in suspense any longer: renal physiology, the global TB epidemic, and esophageal varices are all related in that I spent a very long day yesterday dealing with them. I started off with two hours of Dr. Hanss' physio lectures, and then rushed over to Columbia for the TB Alliance Reversing the Tide of Tuberculosis symposium. The symposium was held in Low Library, which was kind of exciting since I had never actually been inside the building while I was studying at Columbia. Jeff Sachs opened the conference, and then a host of familiar faces were either involved in the presentations (i.e. Josh Ruxin, one of my readers for my Master's Thesis, was a moderator) or as audience members. There were talks from drug and diagnostic development companies, the Vice-Minister of Health for Mexico, as well as many others. On the whole the presentations were interesting, though the symposium was running late so they constantly had to cut people short, and there wasn't as much discussion and I would have liked. Still, the TB Alliance is a group I am interested in working with, so this was a good look at what the group does. I had wanted to stick around after the symposium to try and talk to some of the people who work there, but I had to run off to the train so I could get across town to Elmhurst.

I got to the ER at Elmhurst around 6pm, and things were relatively slow. There was a patient dying of COPD with a DNR in the trauma room, and the whole family was around and emotional. The wife actually was making suicidal comments, and wouldn't let go of a bottle of morphine that she threatened to drink, so psych had to be called down to evaluate her state. The husband was sent off to hospice care upstairs so he could be more comfortable. Dr. Okuda was extremely helpful and willing to talk through some of the cases, and offer a perspective of what life is like in the ER. I really enjoyed the time we had to just talk about how things are run down there. I also got a chance to spend some time with Dr. Clint Masterson, who is an ER resident that is coming on the Belize trip to OrangeWalk. He was also extremely nice, and let me hang around while he was taking care of some patients. When the ER finally got busy around 7:30pm, we saw a woman with a GI bleed (probably from esophageal varices), a 98 year old man who fell down 15 steps (he was called in as a red trauma, but ultimately he ended up being perfectly fine, not a single bone broken), another man who was drunk and fell down a flight of stairs (and was massively bleeding from his scalp-- I had to apply pressure to try to stop the bleeding), a 27 year old man who dislocated his shoulder playing soccer, a elderly woman with COPD who got excited when her son was in an argument with his neighbor, and stopped breathing, and a 80 year old man who was suspected of having a stroke. Dr. Okuda said that there wasn't any case that was tremendously spectacular, but I thought on the whole there was a lot of excitement. Truthfully, when I left at 11pm, it had felt more like 15 minutes had gone by, not 5 hours.

So today is the 8th of March, which means that we are leaving for Belize in less than a month. This is really starting to stress me out, because I really don't think we are where we need to be in the planning stages of the trip-- at least I don't feel comfortable with all the information I have from Peacework to feel that the trip would run smoothly at this point. And there is so much that still needs to happen in the next four weeks that I'm sure is going to go by in a blur: I have to finish preparing for Belize, we have to take 3 exams (two finals and a midterm), I have to take my trip to Chicago for the AMSA Convention, I'm going to have a number of phone calls for the Global Scholars Program, I have to be clinic manager at EHHOP, we are starting two new courses, and I have to pretty much figure out my plans for the summer, since the funding deadline is while I'm going to be away. All of this is quite depressing, actually, because I know I'm not ready for any of it. I guess it has to happen though.

Also, not sure how long it'll be on the web, but the AMSA Global Health Scholars website for this year is up. There is something satisfying to having your life summarized in approximately 200 words.

'Cause in my head there's a Greyhound station

2006-03-05T13:53:00.000-05:00

So I spent most of the day reorganizing my life by finding a place to put most of the clutter that was taking over my room (and thereby my life), listening to Death Cab for Cutie, mourning Duke's loss to UNC last night, and hiding from old man Wheater's Histology. By the looks of it, i's a nice day outside, and I'd like to get out into the sunshine at least for part of it. I'd also like to make it to the gym downstairs as well, but that's contingent on me finishing the Physio quix before dinnertime. Even so, it feels good to be about to walk around my room again (and not trip on cardboard boxes, shoes strewn around the floor, and other equally random objects) and be able to actually find things when I'm looking for them.

I've got a bit of a rough week coming up, since it's the week before the Histo exam (which I absolutely can't get excited about, even though it means that we'll actually be finished with the worst "real" class in med school so far). Tuesday is a wash in terms of studying because I'm going to be running around the city, first for lecture here and then the TB symposium at Columbia (Jeff Sachs is doing the keynote), and afterwards I'm heading to Elmhurst to shadow Dr. Okuda in the ER until 11pm. It should be a very long, but hopefully good day.

All I have to do now is get excited about renal phys.

Children = evil.

2006-03-04T14:49:00.000-05:00

It seems that I do the bulk of my posting after days at EHHOP. Today I was working there as a Junior Clinician, and I was able to see one Mexican patient who came in for a routine physical exam. She was a nice lady-- 23 years old with two children, ages 3 and 5. Her mother is 38 years old, which means that by the age of 33 she was already a grandmother, which I think is pretty crazy. Anyway, she needed a PPD and a tetanus shot, so the Senior gave her all that-- all the while her two children were absolutely reaking havoc on the examination room: throwing latex gloves in the air, opening every drawer and playing with the otoscopes, etc. They just could not sit still for a minute, which made it incredibly difficult to try to translate a history and do a physical exam. In just the hour or so that we were with the patient, I got absolutely exhausted by having to constantly tell the kids not to run around the room. I can't even imagine trying to treat children on a daily basis. It would be a nightmare.

Since immunology/allergy is a field that deals mainly with infants and children, it's starting to fall a few rungs in my list. To be honest, the only thing I could really see myself doing right now is EM, and possibly Med/ID. Possibly. I'm not thrilled with the idea that ID's main job is consults from other physicians, though. All I do know though is that children are evil, and I can't imagine taking care of them.

MICU

2006-02-28T15:55:00.000-05:00

So today I met with Dr. Thomas Kalb, a Pulmonology/Critical Care physician who works at Mount Sinai's Medical ICU. I didn't get a chance to shadow him because he had some family matters to take care of, it was great to get a chance to talk to him for a while. He was a really nice guy to talk to, and was really interested in hearing about what I want to do and telling me about pulmonology. He thought my decision to do the MPH before medical school was a great idea, and it would be very beneficial during the learning process in medical school. He also really supported my interests in global health, and gave me some advice as far as what I can do with that. He said that in general, critical care is a technology-dependant field, and is really not relevant to situations in the developing world. If I wanted to have skills that could be used in other parts of the world, I should either look into general surgery or ID. Those are the two fields, he said, that have the most in common with global health work. Not to say that pulmonology is not important, but there is only a limited amount of work that I would be able to accomplish with it. I thought that what he said held a lot of truth-- and I think this is where my interest in global health comes into conflict with my desire to be grounded in one place and be financially stable. I genuinely think that is is possible to do both, but I'm not sure if I have found out the right way to do that yet. Still Dr. Kalb was extremely nice to me, and offered me a chance to round with him after his teaching duties are over for the year, some time in early June. I'm not sure how I'll feel by that point, but I think I'll take him up on that offer.

After thinking about what he had to say, I don't think I would count pulmonology out, but it certainly has moved a little further down my list. Walking through the ward on my way out made me realize that all the patients in the MICU are generally elderly, and are all attached to a machine of some sort. It was remarkably quiet on the floor, and there was just this sense of keeping people alive using machines.

The Belize experience has made me think a little more about ER, because that seems to be a field that be highly involved with global health (at leave three or four of the physicians coming with us are ER docs), has reasonable hours and lifestyle (on a shift, so no phone calls in the middle of the night), is compensated quite well (avg. is $200,000) and has only a 3 year residency that isn't horribly competitive (according to this website, it's middle of the pack: a relative competativeness rating of 0.84, as opposed to derm which is 1.26 and medicine which is 0.53). I'm going to try to shadow an ER doc at Elmhurst sometime in the near future, as soon as I get a hold of him.

Late night thoughts on histo...

2006-02-26T23:09:00.000-05:00

"Wet Seal"

Conference Call

2006-02-26T12:24:00.000-05:00

I just finished a conference call with the other members of the AMSA Global Scholars Program, where we talked to Saranya Kurapati, the health action organizer for Physicians for Human Rights. It was great to listen, even for a brief amount of time, to someone who is very comfortable talking about issues surrounding human rights on a level that is far more sophisticated than the conversations that we have among medical students. It made me realize how different all of this is from the types of discussions we were having at Columbia. And I don't think it has anything to do with Sinai-- this is the nature of medical school. I was talking with my roommate about this kind of thing, and he was commenting that he feels that everyone has this nature of being so self-absorbed, only worried about how to pad their resumes and what subspecialty they are going to do. There is something about school that can be so all-consuming, so homogenous, that it is impossible to have outside beliefs or interests or plans. This may be a cynical thought, but I am still tired after that first round of midterms that we had, and the prospect of starting to think about the final exams in Histo and Physio is disheartening. Things with Belize are starting to pile up, and I find that summer plans are being pushed to the back burner. All that manages to do is get me more anxious.

The Global Health Scholars are going to have a conference call with Stephen Lewis in a few weeks, which I think is very exciting. He worked at the CGHED while I was there, and I saw his speak a number of times at Columbia, he's a wonderful speaker.

I went to an ID panel this past Tuesday which was really interesting. It felt very comfortable to talk to ID docs about the diseases that they work with on a daily basis, and I think that I could do something along the lines of what they do. Although, as far as doctors go, ID docs kind of get the shaft I think-- they are up there with peds as getting the least respect for what they do. It really bothers me that some surgery subspecialties do nothing more than the same hernia surgery every single day, day in and day out, and receive an enormous amount of compensation and respect, while subspecialties of medicine get none of that. I heard a pulmonologist talk on Thursday, and that was really cool I thought. I'm going to try to shadow him this coming week.

Here is a table from the WHO Global Burden of Disease Project that gives an estimate of diseases or injuries with the highest mortality rates in 2020. There is little I would be able to do about road traffic accidents, war and violence, and I really don't think I want to work with mental health issues (i.e. unipolar depression and self-inflicted injuries) or with obstetrics (i.e. perinatal conditions and congenital anomalies). That leaves CVD (HD and stroke), ID (diarrheal disease, pneumonia, TB and HIV) and lung diseases (COPD and lung cancer). Fully four of the fifteen diseases are related to the lungs (pneumonia, TB, COPD and lung cancer). Of course these are data from all over the world, and different parts of the world will have different rates of diseases. It is quite interesting that the major diseases of the world are still related to ID, heart disease, and lung disease.

Rank of diseases and injuries attributed to the highest mortality rates, 2020

1	Ischemic heart disease
2	Unipolar major depression
3	Road traffic accidents
4	Stroke
5	COPD
6	Pneumonia
7	TB
8	War
9	Diarrheal diseases
10	HIV
11	Perinatal conditions
12	Violence
13	Congenital anomalies
14	Self-inflicted injuries
15	Trachea, bronchus and lung cancer

Alright, renal physio calls, so I'd better be going.

Global Health Scholars Program

2006-02-10T21:56:00.000-05:00

I got a phone call yesterday telling me that I had been accepted by the AMSA for the Global Health Scholars Program, which is a new certificate program for medical students interested in global health. It was a pretty competitive program-- out of about 100 people who applied around the country, they said, they interviewed 10 students, and accepted 4. One is from Yale, the other is from GW, and the third I can't remember. Anyway, it involves a 6 month curriculum of sorts and a couple of stipulations for things we have to do to finish the certificate. The first step is to read Paul Farmer's Pathologies of Power, and then in April we are going to have a conference call discussion with him about his work and the topics in the book. I think that is very exciting-- I saw Dr. Farmer give Grand Rounds at Columbia once while I was there, and he gave a very inspiring talk. On top of that, there is a chance that they are going to want the four of us to sit on a panel during the AMSA National Convention that is being held this April in Chicago. Again, also very exciting. Of course, all of this means more work, but it's still some great opportunities.

In other news, I took my Histo exam this past Monday, and it was overall a very frustrating endeavor. The questions were overly ambiquous I thought and I spent more time trying to figure out what they were asking than actually thinking about the correct answers. Sufficed to say I didn't do a stellar job-- enough to pass, but not enough so that I can coast through the final. Stupid practical. If there was any doubt about pathology before, I think I can safely say that it's definitely out of the running now.

I started my elective in Clinical Immunology today. It was kind of strange, to be honest, since it was just me and another student sitting in a room as this pediatric allergist gave us a talk that she have given that week to immunology residents. I must say that I think I understood a lot of it, but that was from an amalgam of personal experience and stuff I sort of remembered from the NIH. On the whole, it was somewhat interesting, but I kind of got a sense of it being dry and even a little boring. I don't know. We have another session next Monday and another one on Friday, maybe those will be more exciting. I mean, it doesn't have to be anything out of an ER episode, but I was just thinking about what Eric is doing for his elective (scrubbing in on ENT surgeries), and even though I don't think I'm going to end up doing something like that, it still sounds far more interesting. This week my specialty-of-choice is critical care. I'm not sure if I would be able to work in an ICU, but it seems to have a little bit of everything. I emailed a pulmonologist who works in the MICU to see what he has to say. I'll keep you posted.

Unusually warm day in January

2006-01-30T00:27:00.001-05:00

And I'm at my desk.

Have midterms coming up: Histo a week from tomorrow, Physio the following Monday. Having a hard time getting motivated. I just don't love the material. Plus there are so many other distractions, like Belize, summer plans, apartment hunting, etc...

We had a couple of exciting things this week: on Wednesday we got our first experience with the human simulator program, and saw some pretty cool "real-life" situations. Later that day we had our first ASM clinical site rotation. I'm paired with Christian Garcia, and we're shadowing Dr. Michael Serlin, and ID attending at North General Hospital in East Harlem. We got to take histories and physicals on two patients, one with many infectious diseases (HIV, TB, syphillis, chyptococcal menningitis, etc) and the other with many chronic diseases (COPD, emphysema, hypertension, diabetes, etc). Then today was our first training session for the new EHHOP clinical managers. We have to come in two more times and shadow current clinical managers, and then by the beginning of May we'll be running it ourselves. That should be pretty exciting.

Keila left Sinai for the year. She's planning on coming back next Fall, but she'll have to start first-year again. It's sad to see another fellow SEP-er go.

By the way, the weather forecast is predicting snow tomorrow.

One semester down, seven more to go

2006-01-22T12:46:00.000-05:00

I realize that I haven't written in a while, and I can't help but feel that as I sit here in Levy Library, all I'm managing to do is procrastinate.

I wanted to check in though. We're half way to the midterms of Histo and Physio, and I'm not loving the subject matter, I've got to be honest. It's been a bit boring, and I'm hoping it picks up. We are going to clinical sites this Wednesday with ASM, and I'm hoping that helps to pick things up.

I'm having a really hard time deciding what to do with my summer. No matter what idea I come up with, it seems to come to a dead end. There hasn't been a lot of support from faculty and administration (all my emails remain unanswered), and I'm starting to feel just as frustrated as I was before my trip to Mozambique two years. I know that if I end up volunteering somewhere on my own, I probably won't get a paper published, which should be a goal of mine. At the same time, I have absolutely no interest in sitting in a lab this summer, or working around the schedule of a Sinai professor.

So right now things like apartment decisions, summer plans, and Belize are much more stressful than class, which seems more like a distraction than the purpose of me being here.

I am just worried that things will things are going to get much more stressful when the classwork piles up.

Let's play the "Choosing a Specialty" Game! (Part 2)

2005-11-12T20:22:00.000-05:00

So I doubt this list has changed much since the last time I played this "game," but the reason I'm doing it again is that now I have a more complete list of medical specialties (this list includes all the possible specialties someone can place into for residency programs). What I did was rank all the specialties from 0 (I could never do) to 5 (I could definitely do), and then put them in order of ranking. The top and bottom of the list didn't change much, but the middle of the list moved around a little. More than half of the specialties are in the 0-2 categories, so for right now, there is a pretty reasonable likelihood that I won't be pursuing any of those paths. That limits my interests, but not too much-- so I think I'm in a good place.

5 pulmonology
5 otolaryngology
5 ophthalmology
5 infectious disease
5 allergy & immunology

4 thoracic surgery
4 general surgery
4 general internal med
4 emergency med
4 anesthesiology

3 preventive med
3 orthopaedic surgery
3 occupational med
3 neurosurgery
3 med oncology
3 hematology
3 cardiology

2 pediatrics
2 pathology
2 neurology
2 nephrology
2 family practice

1 rheumatology
1 radiology
1 radiation oncology
1 psychiatry
1 plastic surgery
1 physical med & rehabilitation
1 obstetrics/gynecology
1 gastroenterology
1 endocrinology
1 dermatology

0 urology
0 nuclear med
0 colon & rectal surgery
0 aerospace med

And for future, future reference: this site has a "competitiveness" scale for residency specialties. Just so I can start freaking out now, 2 out of the 5 specialties that I ranked 5 out of 5 (Ophtho and ENT) are among the 5 most competitive specialties (along with Plastics, Derm and Neurosurg, which I don't care much for). So does that mean I have to turn into a gunner?

Trauma surgery @ Elmhurst

2005-11-12T19:37:00.000-05:00

I'm apparently making a habit of posting to this site only after my week is over. It's almost 8pm on Saturday night, and I am exhausted. I just got back from spending the day shadowing in the Department of Surgery at Elmhurst Hospital in Queens. I got there at 8am, which was just in time for a red trauma call: an HIV+ drug user had been brought in after having been held up at gunpoint and then stabbed in the throat by his neighbor. The patient was being wheeled in as I walked in, so I didn't even have time to change into scrubs. After a tense hour or so, I followed the surgical team on its rounds. The stab patient ended up being fine: I saw them do an angiogram of his aortic arch and great vessels to see if there were any lesions, and I also saw an esophagram. Both came back negative. As I left tonight he was being stitched up, and was going to spend the night in the hospital and probably be discharged in the morning.

I saw a number of other patients that were on the Surgery team's service today, including a 20-week pregant woman with signs of appendicitis (major epigastric and LRQ pain, extremely high white cell count), a Riker's Island inmate with HIV and a severse case of anal warts, a 14yo with appendicitis, a Peruvian man with cholecystitis and a history of appendicitis and peritonitis, a man with MRSA who recently had a left lung lobectomy, a woman who fell off a porcelain sink and had a hugh laceration in her right gluteal region, and a HepB+ Chinese man with esophageal varices caused by portal hypertension (he was bleeding profusely from his mouth, and probably wasn't going to make it through the night). I found the last case to be particularly interesting because of the amount of time that Dr. Laitman spent on collateral sirulation routes in the body, especially between the portal and caval systems. It's one thing to try to memorize the routes of circulation for an Anatomy exam, but it's something else to actually see someone dying from it.

The experience at Elmhurst was really remarkably interesting. I don't think it hit me as something that "I want to do for the rest of my life," so to speak, but I found it to be exhilarating, and on a couple of occasions I found myself thinking: "I think I could do this." This says a lot considering that I've always thought that surgery was something that I wasn't cut out for. It can be intense, but also immensely interesting.

The rest of this past week was about me recovering from my M&C exam on Monday. The exam was alright, which was amazing since I really didn't feel prepared enough for it. They could have definitely made the exam more difficult that it was. I couldn't say whether I beat the curve, but I might have been more or less close. It depends on how other people did. The problem was, though, that since I spent most of last week locked in the library, I started this week low on sleep, and so these past couple of days just seemed to drag on forever. Some things of note this week were: in Anatomy we opened the skull and exposed the brain-- and then ripped it out and exposed the cranial nerves-- and then cracked the frontal bone and popped out the eye; we had our first Belize trip meeting with the people that are actually going on the trip, which was successful; we practiced our history-taking in ASM with a standarized patient (an actress); and on Thursday I gave my first shot, which was 0.5mL of saline, to Milla (which she then reciprocated).

I must say, these weeks have been long. I have been genuinely tired. But it has never been boring. I still have doubts every now and then abut whether I really should be here or not, but I can't ever say that it's not something that's been really interesting so far. I'm having a great time, not considering all the adjustments that I've had a tough time with.

Hiding out in Levy

2005-11-04T17:26:00.000-05:00

I'm sitting in Levy Library as the sun is setting over Central Park, and I was thinking about how this has been a long, long week.

On Wednesday we had a clinical correlate through M&C with a 25 year old girl named Gail who had acute myelogenous leukemia (see more about AML here). She had gone to Emory for college, and knew some of the people from New Rochelle who had gone to Emory (since she was my year in college). She was diagnosed with leukemia her senior year in college, and went through the terrible chemotherapy and treatment. She said she remembered feeling fine at the time of her diagnosis, but being told that she had to go home and be rushed into the hospital for treatment. She shopped for a few doctors in New York while bringing her luggage into the doctor's office, because she fully expected to be admitted as soon as she chose which doctor would treat her. On one night during her treatment she remembered having a 105 degree fever, a 0 neutrophil count (anything below 1000 is considered neutropenic), and a 60/40 blood pressure. Her doctor had called her parents to ask them to come in the night because they thought that Gail might not make it through the night. I imagine that must have been such an incredibly hard thing for her as well as her family to deal with. Gail said, though, that the entire time she was in treatment, she never slept in her hospital room alone: she always had a family member there to look after her. She said that was such an important part of treatment and recovery. Another interesting thing about her case was that she was supposed to start her chemotherapy on September 11, 2001, but after the terrorist attacks Sinai had to push her therapy off indefinitely because there was a question of whether there would be a major strain on the healthcare capabilities of NYC. Because there were so few casualties from the World Trade Center attacks, though, Sinai ended up with a surplus of medical supplies, and Gail's treatment began a week behind schedule.

After Gail we met with another patient through ASM that same afternoon. Nick was a 58 year old male who at one time had been an alcoholic and heavy drug user, but has been sober for more than 20 years. He talked to our small group a little bit about his life and what made him turn to alcohol as well as other drugs (including amphetamines, barbituates, cocaine, and heroin, among others), as well as how it affected his life and what made him seek help. He said that one day he got a letter from a priest he had known while growing up in Greece, inquiring about how Nick was doing, and to write back to say what he had been doing lately. The letter made Nick realize that he had absolutely nothing good or of value going on in his life, and decided to start attending AA meetings to see whether he couldn't change his life around. After going in an out of AA a few times, he made it through the 12-step process, and has been sober ever since. He met his current wife while in AA, which he said has been a great improvement in his life, and has had a job in the NY prison system for the past 15 years or so. It was really interesting to talk to him about alcohol and drug abuse as a disease, and see how difficult it was for him to go through treatment and rehabilitation. I think the students in the small group didn't pass any judgment about Nick, and asked good questions about different aspects of Nick's life. This was an exercise in talking to patients about uncomfortable topics such as sexual and drug histories.

I met with Ann-Gel from the Center for Multicultural and Community Affairs this week to talk about getting in touch with physicians who work in fields that interest me, as well as starting to talk about research plans for next summer. I know that I am interested in somehow structuring a project where I can do part of my work abroad for about a month, and then bring the project back to East Harlem for the rest of the summer. My problem (as I mentioned in a previous post) is that I don't exactly know what field I want to work in, and don't necessarily know where to begin without having had much clinical experience. Ann-Gel was really helpful in giving me some ideas of people I could talk to, and was very serious about getting me organized and working on a gameplan from now until next summer. I'm excited about the prospects of what I am going to do, and I have to keep on telling myself to think about more pressing issues at hand (i.e. my M&C exam that is in 3 days). The CMCA has a scholarship for a few students to do research each summer, and I think it would be great if I had my act together by then to apply for it.

This past Tuesday was the last day of the Extremities section of Gross Anatomy. That meant that this Thursday we started out final section, the Head and Neck. At the beginning of class we took the final wrappings off of our cadaver's head. It was a very surreal--and somewhat disturbing--experience to finally see her face, and to think about her very much as a human being again (not that we didn't think of her that way before, but I guess it is easy to dehumanize a cadaver when looking at such such small parts of her body at a time. Also, the face is by far the most human part of the body). The lab was the most solemn it has been since probably the very first day of dissection, and it involved skinning the cadaver's face and exposing the muscles involved in expression, which seemed like it was something straight out of a horror movie. It was also really interesting that it was virtually impossible to tell what the ethnicity was of our cadaver until we removed the head wrappings-- and then it was very obvious that she was of Asian descent. She was a 78 year old woman who died from COPD and heart problems. One of my suitemates said prior to our lab on Thursday that he was a bit nervous about going through with the lab, and that he had had a dream about uncovering the head wrapping of his cadaver and seeing his own face. Overall, a very surreal experience.

We had a lecture from Dr. Hausman, who is Chief of Hand Surgery at Mt. Sinai, about hand anatomy and how it relates to some of the surgeries he performs. It was a fascinating lecture about how they are able to "harvest" other structures in the body (i.e. toes, tendons in the leg like the plantaris, or the acromion of the scapula) and reconstruct broken or deformed structures in the hand. It was amazing to see that they are able to recreate functions and movements using parts of the body that have absolutely nothing to do with the hand. Every surgery is virtually a completely different surgery, and requires the surgeons to design surgeries based on each case's individual needs. It's just amazing what they can do.

I also went to a talk earlier in the week about post-medical issues such as salaries for different specialties, and how much we can expect to make as physicians. It was a very depressing talk because the panelists gave a number of examples of why we're not going to be making very much money because of overhead costs, declining charges for procedures, and malpractice suits. They said that one of the only ways to make money is to start your own practice, which requires almost more business experience than medical experience. Granted, the panelists were not really involved in things that interest me, but still... it's hard to look at the end of the tunnel and be told that I can only expect to be worked to the bone and receive very little compensation when I get there.

Today was the last day for first-year students to hand in deposits for the Spring Break trip to Belize, and so in a meeting this afternoon we were able to finalize the lists of who will be going to which site (either Orange Walk or San Ignacio), and what their responsibilities will be. I think we have a good group of people going to OW. I'm glad that things have been coming along very smoothly, and I'm getting excited about going on the trip. Hopefully the task of trip preparation and coordination will be fairly smooth since we've got a good network of second-years who went last year and are willing to help us on this year's trip.

This afternoon Christian and I met with the geriatric patient were assigned to through the Seniors as Mentors program in ASM. Her name is Ms. Valentin, and she is a 75 year old Puerto Rican woman who lives a few blocks away from Sinai. She seems to be very nice, though she would much rather watch TV than do anything outdoors, and doesn't seem to want to do too many things. We're going to give her a call sometime next week, and then try to set up a meeting with her sometime in the week after that. Some other students (including Eric) have been through 3 or 4 seniors already, so I guess we have been fortunate to be with someone who is interested in the program.

This post has been long, and now that it's dark outside I think it's time to start on some M&C. I have a feeling that I will be hiding out in this little corner of Levy Library, where people can't find me unless they are looking for me, for many, many hours.

I wanted to close this post with a quote, though:
"The reasonable man adapts himself to the world. The unreasonable man persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man." -- George Bernard Shaw

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

2005-10-31T18:53:00.000-05:00

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

2005-10-29T18:36:00.000-04:00

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

2005-10-28T12:27:00.000-04:00

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

2005-10-27T21:26:00.000-04:00

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)

2005-10-27T00:04:00.000-04:00

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

2005-10-23T14:44:00.000-04:00

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

2005-10-18T22:57:00.000-04:00

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!

2005-10-12T14:31:00.000-04:00

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)

2005-10-10T01:12:00.000-04:00

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

2005-10-09T13:52:00.000-04:00

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

2005-10-08T11:16:00.000-04:00

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.