Sunday, December 20, 2015

The Adventures Continue

This time it has been 6 months.  The delays in my posts get longer, but life proceeds at its frenetic pace.  And there is much to update y'all on.

1.  Senior Resident
It's been interesting being a senior resident and overseeing the brand new baby interns.  There are 2 overwhelming thoughts: 1.) It's crazy how much I've grown as a resident and as a doctor, 2.) I have a new-found appreciate for my senior residents when I was an intern (and I found myself doing some of the things they did!).  I've also developed an unofficial "rule" for a well-functioning team: the team that laughs together, works well together.  :-)

2.  Fellowship Interviews
For most of September and October, I've been busy with fellowship interviews.  I decided to pursue a fellowship in pediatric rheumatology after all.  There are few fellowship programs in this field and oddly even fewer applicants!  It's not a well-exposed or popular fellowship.  But hey, I guess that works in my advantage.  Here are pics of some places I've interviewed:

 Cincinnati, OH

 Pittsburgh, PA

Ann Arbor,MI

Seattle, WA

3.  Another Away Rotation
Yay another away rotation!  This time in pediatric dermatology because, well, I suck at dermatology.  And knowing some dermatology will be useful for rheumatology in the future.  See if you can figure out where I did my rotation from the following pics:

4.  Match Day
And about 1 week ago, I found out that I matched fellowship in Pacific Northwest.  That's exciting.  I'm a tad annoyed that I didn't match in the Bay Area, as my odds were higher of matching there.  Oh well.  I can't ruminate on this for too long.  I must admit, it's probably the better program.  I was willing to "sacrifice" some career potential in order to be closer to family and focus a bit more on social life, which has been on hold for so long.  But it seems that the universe has other plans for me.

5.  (Lack of) Social Life
Yup.  Still single.  Not for some lack of trying, but maybe I'm just doing it wrong?  Maybe I'll find someone in the area where I do fellowship?  Should I remain always hopeful?  I don't know.

Sunday, June 14, 2015

Found and Lost

I've become worse and worse about posting.  Sorry.  Residency has been busy and I've been too tired/lazy in what little free time I have to reflect.  But as I'm on vacation this week (and my original first and second plans fell through), here's Part 1 of several updates.  Without further ado, Part 1: Found and Lost.

So in my last post, I mentioned Pikachu.  We did end up going on a trip to the Big Sur area.  It was an amazing (albeit too short) trip.  I'm always stunned at how gorgeous the coastlines of this state are!  Here are some pics (from just the first day):

Big Sur coastline

Bixby Bridge

Valley View

Pfeiffer Beach (yes, parts of the sand are purple)

More stunning coastline!

And the iconic McWay Falls

We had a great time!  Yes, we did fool around a bit in bed at the hotel.  That was not planned but practically expected.  I won't elaborate much here, but suffice to say he's a passionate kisser and left me with a few hickies (which was a bit of a problem hiding behind my collar in clinic the following Monday, lol).  More than anything sexual though, it was just nice to lie next to someone and cuddle.  It's a wondrous thing, the sensation of touch.

Suffice to say, by the time we parted ways I had fallen for him.  But then an odd thing happened.  His work really picked up speed and he became very stressed out and distant (presumably from all the work he had to do).  We had gone from texting/Skyping almost every other day to just a couple times a week.  I continued to say "Hi" and "Good morning" almost every day for a while with a scarce reply.  I was beginning to wonder what was going on.

When we finally carved out some time to chat on Skype, I confessed that I really liked him in a way that I hadn't felt towards many other people before.  He took it as a compliment but didn't elaborate much more.  Later he would go on to say that long-distance never works out.  He was referencing a friend and her long-distance relationship, but I took it as a sign that we weren't meant to be (at least, not at this time).  The distance between us is about 2.5-3 hours' drive, and he categorically refuses to come to my part of the state.

And so perhaps that was it.  It almost felt like things evaporated away.  We still text and chat from time to time, but it's mostly me doing the initiating.  I feel the gulf of distance and at first it ate away at me.  Yeah, I still have feeling for him and I wonder if I were to match fellowship near him, would we have a chance?  Or would he find someone else in the intervening time?

I let my guard down.  I let a mask fall.  I let myself feel vulnerable.  And things didn't go as I had hoped.  I hate this feeling.  And what's worse is the feeling that I may very well end up alone anyway.  My 20s are quickly fading with each advancing day - is there any hope for this remaining time?  Or will I find what I seek in my early 30s?

Sunday, February 15, 2015

Happy Single's Awareness Day

Wow, it's been about a month and a half since I last posted!  I suppose a few things have happened in the interim . . .

So I guess the focus of this post will center on this guy.  I'll call him Pikachu because he likes Pokemon.  So I met Pikachu back at the end of December 2014.  We had chatted on/off for months on a dating/hook-up app (no, it's not Grindr) but since we lived about 3 hours away from each other, we never had the opportunity to meet until December.

Since then, we've been texting each other almost every day.  More recently over the past 2 weeks, we've been Skyping about every other day; sometimes it's only for 10-15 minutes but other times it's been over an hour.  I've got a vacation planned for the end of this month, and we're planning on spending 2-3 days together on a mini trip/hike of the Big Sur area.

I think I'm beginning to really like him.  It's been quite a while since I've thought that way about anyone.  I've chatted with both guys and girls on/off via online dating sites/apps for the past 2 years.  A few of them (mostly girls) have made it past that to texting.  But then it fizzles out when my schedule becomes busy.  They don't initiate conversation and I can't sustain it one-sided.  But with Pikachu, he texts me in the morning to say "Hi" or "Good morning."  Simple as that.  But it keeps things going.

I was feeling the Single's Awareness Day tonight, and I texted him if he wanted to Skype.  At some point during our conversation it came up that I was bi.  Although I'm like 95% sure I had mentioned that fact to him when we first messaged on the dating app, he must've forgotten.  But his reaction was predictable, understandable, and . . . unfortunate.  He was taken aback a bit and seemed unsure for a moment.  He explained that he didn't mean it but stated that "biphobia" does exist in the gay community.  He had dated a bi guy within the past several months and it didn't go well (it didn't get very far either).

This brought up all sorts of insecurities for me.  I wasn't expecting that.  I thought I had moved past that.  I guess not.  On a spectrum of 0 to 10, with 0 being 100% straight and 10 being 100% gay, I place myself somewhere between 7 and 8.  In general, I'm more physically/sexually attracted to guys (girls have a narrower range), but I'm more emotionally/intellectually attracted to girls.  Pikachu is the first guy in a long time - possibly ever - who I've felt a romanto-emotional connection to.  And a part of me feels just broken after his reaction to me clarifying that I'm bi.  And honestly, I'm not even sure how well that label applies to me anymore.

I'm not sure how to navigate these feelings.  No, that's not accurate - I don't know how to navigate these feelings.  It's easy for me to just box it up and store it away, but that's not what I should do.  It's easy for me to tell myself the same advice I offer my patients, but it doesn't feel easy to follow.  It could be just me, but I feel like the fact/label of being bi has changed the relationship dynamics in ways that can't be undone.

Sigh.  :-/

Wednesday, December 24, 2014

Skepticism Against Non-Neutrality

This is a follow-up to my previous post, Media, Culture, and Half-Truths.

As I blogged that post, the media in other areas were already aflame with skepticism.  To recap from my previous post, the US CDC is considering a recommendation that medical providers should discuss the benefits of circumcision and offer it to parents and any uncircumcised male teenager and young adult (particularly those in a higher sexual risk group).  This is part of the US CDC's plan to help further reduce the incidence of HIV/AIDS.

And as I blogged in my previous post, this thread of logic is misplaced and damaging.  I even posted a comment on the US CDC's site.  It's open for commenting between Dec 2 and Jan 16.  The vast majority of the comments on that site are negative towards the new recommendations.  Here's an article that reflects that:

There is also a nice and succinct article on an Oxford ethics blog, A fatal irony: Why the "circumcision solution" to the AIDS epidemic in Africa may increase transmission of HIV, by Brian D. Earp in 2012.  It basically summarizes my thoughts from my previous post (but more eloquently written).

Again, this is not a new topic of debate.  The US CDC first began considering this back in 2009, but had delayed making notable public announcements until now.  As evidenced by an article in the Huffington Post, Male Circumcision and the HIV/AIDS Myth, by Dr. Ali Rizvi.

Heck, this topic has been covered (albeit tongue-in-cheek) by Queerty!  For example:
And to reference my previous post, the media can write about a single topic in two ways.  Queerty is clearly on the opposite side of the articles posted in my previous post.

So anyway, read the links if you desire.  They're there.  I'm a broken record on this topic.  No more on this until the US CDC finalizes its recommendation, one way or the other.  But for the love of democracy, please comment on the link above if you have an opinion you'd like to share!

Wednesday, December 3, 2014

Media, Culture, and Half-Truths

This is nothing new.  Just warning you now, this is going to be an epically long post.  I've read about this before and I've discussed it before on this blog.  But this topic resurfaces rather frequently.  I see headlines such as:

This is a controversial topic.  There is intense debate among physicians and even residents.  It's a subject that's almost taboo to talk about.  So let's talk about a few things: Media, Culture, and Half-Truths.

I took a course in scientific journalism and media in undergrad, and I walked away from that class appalled.  So much so that I was literally unable to even look at a news article about a scientific or health topic without feeling an intense pang of rage for almost half a year.  Here are some things to know:

The media skews towards catchy headlines.  Sure "Male circumcision benefits outweigh risks, US CDC says" sounds pretty neutral.  But then you have the headlines "Circumcision Guidelines Target Teenagers" and "Feds Say Circumcision Best for Boys," and suddenly those pop out.

The media also has an agenda.  You are supposedly supposed to present both sides of an article (where there are 2 sides to present), but it's almost always skewed and thus almost never balanced.  Take the NY Times article, "Circumcision Guidelines Target Teenagers."  It dedicates a measly 2 paragraphs at the very end on counter-arguments, which although valid, reads as an afterthought.  Take the TIMES article, "Feds Say Circumcision Best for Boys."  There is no mention of any counter-argument.  None.  The LA Times article, "Circumcision cited as defense against HIV in proposed CDC guidelines" is actually the most balanced of the bunch.

The media doesn't understand statistics.  Now, statistics is a difficult concept for even many medical experts to grasp.  So to be fair, the media has no chance.  When presented with numbers, the media will always take the largest numbers presented.  Again, because it's catchy.  For example here, the recurrent phrase that goes "circumcision reduces a man's chances of getting HIV by 50-60%" sounds like a huge deal!  But context is necessary.  That number reported is what's called "relative risk reduction."  What matters to an individual is the "absolute risk reduction."  For instance, let's say the average uncircumcised man's risk of getting HIV is 1 in 1000 (or 0.001%).  So if he's circumcised, his risk goes down by 50-60%, thereby going from 1 in 1000 to 0.5 in 1000 (or 0.0005%).  Well, going from 0.001% to 0.0005% doesn't sound like much of a difference for that individual, and it isn't!  But both numbers could be true.  Going from 0.001% to 0.0005% is a 50% decrease - this is "relative risk reduction," but the "absolute risk reduction" is 0.0005%.  See why the media would choose to report 50% over 0.0005%?  (Note: the average man's risk of getting HIV in the US is WAY smaller than 1 in 1000).

Culture is such a pervasive and unconscious thing that few people even realize it comes into play.  The US, given his history of higher rates of circumcision, has a cultural bias towards that procedure.  Whereas comparable Western countries (Canada, Europe, Australia) don't have this cultural bias.  This is how everyone can look at the exact same studies, the exact same medical literature, and come out with polar opposite conclusions and recommendations.

Here's an excellent article rebutting the latest AAP (American Academy of Pediatrics) guideline update on this topic: "Cultural Bias in the AAP's 2012 Technical Report and Policy Statement on Male Circumcision.

People think of medicine and science as containing immutable truths.  Yet in reality the exact opposite is true.  We must constantly challenge and question old scientific truths in order to get ever closer to the Platonic Truths.

Now on to the merits of what's been discussed/argued for in the articles.  The best quote I could find comes from the LA Times article: 
"Dr. Thomas Newman, a professor of epidemiology and biostatistics at UC San Francisco, says he believes that the medical benefits of circumcision outweigh the risks but that both are small."
This is the closest thing to the truth out there.  Let's look at the arguments on the table:

  • Circumcision reduces HIV risk by 50-60%.  Well that effect is quite small on an individual level, as illustrated above.  Plus, condoms reduces HIV risk by 90-97% when used correctly.  That "additional" 50-60% is rather meaningless.  Furthermore, circumcision offers zero benefit for those most at risk of getting HIV in the US (men who have sex with men, IV drug users).
  • Circumcision reduces HPV and other STI's.  Maybe true.  But we now have a vaccine for HPV that's 98-100% effective.  And again, condoms.
  • Circumcision reduces UTI's in boys during the first year of life.  This is actually true, however, the risk of getting a UTI is rather small to begin with.  In a healthy uncircumcised baby boy, the risk of getting a UTI is 1 in 100.  In a healthy circumcised baby boy, the risk of getting a UTI is 1 in 1000.  In girls older than 1 year of age, the risk of getting a UTI is like 5-7 in 100.  And how do we treat UTI's?  With antibiotics.  That said, there is a role for circumcision in a baby boy who gets recurrent UTI's (and usually there is some other anatomic problem as well).
  • Risk of complications.  I love how they kind of lumped all complications together, and then say that it's about 1% if the procedure is done before 1 year of age, 9% if done between 1-9 years of age, and 5% if older than that.  I don't know about you, but a 5-9% complications rate is pretty high.  And what are these complications?
  • Infection and inflammation are a common one.  As with any invasive procedure, there is always a risk of infection.  And think for a moment, this baby's penis is healing while he's in diapers, exposed to urine and poop.  That can't be pleasant.
  • Bleeding is another common one.  Well, this could be life-threatening if a baby has a bleeding disorder (like hemophilia).  I'm sure the majority of the time no one does blood tests before the procedure to confirm that a baby does not have a bleeding disorder, and often times a family history can only get you so far.
  • Other risks not mentioned?  Adhesions, meatal stenosis, and accidental amputation are ones that probably should be mentioned.
    • Adhesions: baby's bodies heal very well.  Sometimes parts of where the foreskin is removed will reattach itself to the glans (penis head).  This can cause not only cosmetic issues, but also functional issues.  Sometimes those adhesions are so tight that erections can be uncomfortable.
    • Meatal stenosis: when the opening of the urethra (pee hole) is too small to allow urine to pass.  This problem exclusively happens in circumcised babies and requires surgical correction.  The end of the penis is not meant to interact with the outside world before puberty, and so exposure causes inflammation, which causes swelling, which causes a small hole to get smaller.
    • Accidental amputations: yes, very rare, but very very tragic when it happens.  A handful of cases happen each year and it's impossible to remove this risk entirely.  It may be a 1 in a million risk, but if that 1 in a million is you or your baby, and it wasn't medically necessary, you would probably be pissed off.
  • Also none of the articles mention studies that support the foreskin being a very innervated area of the body.  Whether those nerves play a role in sexual sensitivity and enjoyment is a topic of debate in and of itself, but logically it would make sense that more nerves = more sensation.

So you see, the full discussion is more nuanced.  And when I counsel parents on this topic, I present it as I do above.  Thankfully the area that I'm doing residency in has a low circumcision rate, so this rarely comes up.  But it does once every few months.  Most parents who do opt for the procedure are not undecided - it's like parents who're against vaccines, their minds are made up no matter what you say.  So I counsel towards less intervention, at least insofar as this topic goes.

Thoughts?  I know I'm biased, but again, no one has a truly neutral stance on this topic.  Which makes it difficult to fully "trust" the CDC's recommendations (or anyone's opinion, for that matter) on the subject.

Tuesday, December 2, 2014

Where in the World is Aek?

Gosh it's been a long time!  About 3 months since I last blogged!  I would say it's because I've been super busy with residency and all that, but that'd be partly a lie.  Truthfully, I've just been lazy.  Heck, I sat on this post for the better part of a month!  So where in the world have I been?

Well, I've run the gamut from the pediatric intensive care unit (PICU) to outpatient urgent care clinic.  Such a dichotomy in medicine and such different arenas, haha. 

From there I did another rheumatology rotation, but at another institution.  That was an amazing experience!  It was great just being away in a different area, working in a different system, and exploring.  It was also awkward because I felt like I couldn't perform to my full potential because I was learning the system and the hospitals.  It was almost like being a medical student again, almost.

Then I returned and did neonatal intensive care unit (NICU), which sucks as a second year resident, I must say.  You have double the patients to yourself, your patients are way sicker, and you're expected to just know how to manage things.  And on the weekend it can be just you taking care of the entire unit with the attending, which really sucks.

Currently on pediatric emergency department (ED).  It's alright.  I can see why people would want to do it - shift-based hours, sign in/out, lots of potential procedures, patients are in and out rather quick (MUCH quicker compared to adult ED), and you don't have to worry about continuity of care and the frustrations that can sometimes present.  But this is all not quite my cup of tea.  Parents sometimes bring their kids to the ED for really silly reasons.  I mean, if it's not an "emergency" you should really bring your child to his/her primary care pediatrician first . . .  I won't give examples as that may be a HIPAA violation, but if you see and hear the things I have . . .

There's a certain degree of "brain rot" that I feel as a result.  I live for the interesting cases.  The ones that make me think, that make my mind tingle.  On the flip side, as a patient you NEVER want to be "interesting" to a doctor, lol.  And when something could be rheumatic in nature, my mind definitely tingles - like it hungers and salivates for that diagnostic puzzle.

Anyway, to be totally fair, I can honestly understand why some parents bring their kids to the ED even though it's not medically justified.  There are so many factors and when it is YOUR kid, you freak out.  I get that.  I just wished that people utilized primary care as it was intended instead of the ED as their first stop.

Anywho, next post I'll post pics of my adventures.  :-P

Saturday, June 28, 2014

The Fastest Longest Year

Farewell to intern year, the fastest longest year ever!  It's certainly been a crazy ride full of up and down roller coaster emotions.  And boy did the year finish with a bang!  Time to muse on a few thoughts:
1.  Doctors incognito
I've noticed an interesting trend among us "newer" physicians: we never let anyone in public know that we're doctors.  At least not initially.  We never introduce ourselves as doctors, we never use our hard-earned titles in public, and when asked what we do for a living, we'll say something along the lines of "I work in the medical field" or "I work in the hospitals," but almost never will we say outright "I'm a resident/doctor."  Why is that?

In a twisted way, it's almost like a sense of shame or being marked.  Open your mouth and say that you're a doctor and people instantly treat you differently.  Either they ask you about your opinions on this or that (I get the "Should I get a flu shot?" question A LOT), or they ask you about homeopathic remedies, or their negative experiences with doctors comes out.  I mean, I don't go to someone who says he/she is a lawyer and say, "Man, I really hate all lawyers.  They're all scum."  Or "Are you the kind of lawyer who stands in a courtroom and all that?"

As such, I'm never offended if someone calls me "Mr." instead of "Dr."  Although, an interesting thing to note that in Britain, "Mr." is a title ascribed to surgeons whereas "Dr." is a title ascribed to physicians.
2.  The misunderstood adolescent
I may have said this before - I'm one of the few pediatricians who actually enjoys interacting with teens.  Not all teens, mind you, but in general yes.  Anyway, this bodes well especially if I'm really intent on pursuing peds rheumatology (which skews heavily toddlers and teens).

This may be coincidence or it may be intentional, but most of the teens in my continuity clinic are males.  They're such amusing creatures.  I can get most of them to open up at least somewhat (and a handful almost way too much, lol).  I think it helps to understand where many of them are coming from.  And I may be a bit too . . . liberal in my advice to them.

Anyway, there are 3 things I always iterate to every teen guy: 1.) wash under your foreskin (most of them where I am are uncut - good for them, lol), 2.) monthly testicular self-exams, and 3.) ALWAYS USE CONDOMS.
3.  Rising seniors
As interns we are the lowest person on the totem pole that matters (sorry med students, the hospital functions very well with or without you).  We're often abused - intentionally and unintentionally - by senior residents, attending physicians, nursing staff, etc.  It's a frustrating place to be.  But at the end of every intern year is the promise of becoming senior residents and FINALLY stepping out of the intern role.

And at the end of each intern year, it's an opportunity to reflect on the kind of senior we aspire to become.  I've had the good luck to work with one of the best and by far the most hilarious senior residents I've ever known.  Although the last month was rough, he made every day go by quickly and with enough laughter to sustain us.  I can't say I want to exactly be him, I will aspire to carry on aspects of him.

In less than a week, I'll be considered a "senior resident" and I'll have no idea if I'll be a good one or a bad one.  The best advice I've heard was, "Remember what you liked in your senior residents and do that.  And especially remember what you hated done to you as an intern and don't do that."