The Shadow in White

These past few days I've been doing some doctor shadowing - an infectious disease (ID) specialist on Wednesday and Thursday, and my mentor (a pediatrician) on Friday. It might not have been the wisest timing to do my shadowing, what with my first block of exams this coming week (then again, I shouldn't be blogging right now for that same reason . . . oh well).

Anyway, I was a bit hesitant to blog about this in some detail, as I had to look up the HIPAA (Health Insurance Portability and Accountability Act) that would put me in deep trouble if I disclosed certain info. So I looked up the 18 personal identifiers that I'm supposed to avoid. Ironically, we as M1's haven't had HIPAA training yet. Fortuitously, I don't know any of the 18 personal identifiers for any of the patients that I saw, so there's nothing I could really disclose anyway. So without further ado . . . (this post is long).
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Wednesday - ID Inpatient

I spent almost 4 hours of my afternoon shadowing an ID attending, I'll call him Dr. P. I met Dr. P at the LGBT meetings, as he's the faculty adviser for the group. I'm pretty sure he's gay and super nice and kind of funny (I guess I may have a tiny crush on him) . . . beside the point! Once I discovered he was ID, I kind of stalked him at these meetings so I could get his contact info to shadow him. Don't look at me weird, a lot of med students do this.

After wandering around the hospital for a while looking for his office/clinic area, I finally found it and waited several minutes for him to arrive from . . . probably seeing a patient. He came in with another doctor, a nephrologist (who I guess was doing a rotation through the department or something, idk). Anyway, the nephrologist has pretty long hair and amusingly, some of the patients we saw that day referred to him as "Dr. Long-haired." I sat and listened to the nephrologist present a case to Dr. P.

After the nephrologist finished presenting the case, Dr. P turns to me and asks, "So, did that all make sense? Do you have any questions?" After saying no, he quickly responded with "Psh, come on, of course you do. Don't be shy." At this point, my mind was racing to come up with some question to ask. So I asked, "Well, this patient is anemic. Is there a family history of anemia?" Apparently, that wasn't something either of them had thought to ask the patient. WIN. (Ron, if you read this, for the love of God come up with questions to ask - they're hard to think up on the fly.)

The nephrologist leaves and Dr. P and I go to see a patient. I had never been in the areas of the hospital where patients were, so I was instantly lost. The first patient we saw was a middle-aged guy who got an infection in his leg, and they had no idea where it came from or how it got under his skin. So they wanted to take some of his white blood cells, tag them with some kind of radioactive tag, inject his white blood cells back into his body, and see where they go (and hopefully they'll go to where the entry of the infection is).

After that we went to one of the doctor's stations where he typed up a note on the EMR (electronic medical record). He kept all these sheets of papers on his patients folded lengthwise in one of his pockets, which I found amusing. He showed me this one patient of his, who they called "The Train Wreck" because he had been in the hospital for months and kept getting different infections (somehow). They don't know what to do with him. He showed me this guy's labs and he had 3-4 simultaneous bacterial infections. I didn't know a person could be infected with so many bacteria at once, and all resistant to most of the meds they had!

He finished the note and declared that he was hungry, so we were off to have lunch. I just got a sandwich, which he paid for, and we sat and ate together. Being this close, I saw that his left ear was pierced (no idea why I noticed that). We chatted for a bit before heading up to meet with his fellow and M4 for afternoon rounds. On the way he asked me why I joined the LGBT group. I was caught off-guard and gave some lame (but true) answer about how I was interested in LGBT health issues and thought the group would be helpful. Alas, the group isn't (helpful, that is). Dr. P was really concerned about the future of the group because so few students in my class show up to the meetings.

We went up and met with the rest of his team. The fellow presented a case of this elderly woman with an echinococcus infection that they don't know what to do with (echinococcus, a kind of tapeworm parasite, is rarely seen in the US and is considered a "3rd world disease"). The case was frustratingly complicated though I'm not sure I can say more on it. We finally went down to see her in the SICU (surgical ICU). It was so sad looking at this patient and being unable to really do much for her, due to the complicated nature of her illness. You could see the doctors' frustration.

Then we went to the MICU (medicine ICU) to check in on another patient, who was comatose and undergoing a lumbar puncture when we arrived. We didn't even enter the room and I forgot what kind of complicated infection she had; all I remember was that she has liver cirrhosis. After a few minutes of just standing in the hallway, with the fellow explaining her case to me (which, again, I sadly forgot), we went to see the woman whom the nephrologist had presented on earlier.

She was in her 20s, was admitted with pretty serious anemia, and had an ELISA test indicating she was HIV+. When the 4 of us entered her room and closed the door, the tension became palpable - you could almost cut it with a knife (I was never really in a situation where that applied, until now). Dr. P asked about family history of anemia and then began the quiet conversation with her that she might be HIV+. The ELISA test is great for telling someone they're HIV-, but if a person tests HIV+ it may be a false positive. So a Western blot is done to confirm the diagnosis. Dr. P ordered a viral load instead as the Western blot is done elsewhere outside the hospital and takes 3 days to get the results, whereas the viral load test is done in-house and takes a day (but is more expensive).

When we were done talking with her, we stood in the hallway for a few minutes. Dr. P was complaining about how one of the other departments (I think it was pathology) blamed her anemia on the HIV even though it hadn't been confirmed yet. We all agreed it was lame, as HIV can't cause anemia. Dr. P kind of mocked pathology sarcastically, like "Oh look at that anemia, it's HIV's fault. No it's not, that's just lame."

With that, it pretty much concluded my time on rounds with them. They were surprised to get done at around 4pm, as it usually goes for much longer. On the other hand, I couldn't believe how long rounding took on so few patients! Dr. P apologized that I happened to shadow on a day with very complex cases, and kept reassuring me that there are days where the cases are straightforward and you can go home knowing you've solved a case and have definitively helped someone. Not so today, and it was rather House-like.
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Thursday - ID Outpatient

The following morning, I returned to the Dr.P's office/clinic area. On Thursday mornings he does outpatient HIV clinic in the hospital. So we saw several HIV patients. It was much more chill than ID inpatient.

For some of them, he was basically managing their care and serving as their primary care doctor. The patients I saw were really nice and overall pretty upbeat. Several of them were teasing and harassing Dr. P playfully, probably because I happened to be there. More than one was like, "I take my meds because if I don't, this guy here [points to Dr. P] gives me a look that slits my throat with his eyes." At which point, he does. It's pretty funny actually.

One patient was like, "I was in the hospital a few weeks ago and you didn't come to see me! I kept looking and looking for you." Dr. P was like, "Well I didn't know! Do you know how many doctors there are in this hospital? Over 800, and I don't know them all. You should've called me." Dr. P then asked if he had made an appointment with his nephrologist. The patient says, "No, because he's not you." At this, Dr. P wonders if there's something about the nephrologist he doesn't like so he could refer him to another one. The patient reassures him that the nephrologist was a fine doctor, he just wasn't Dr. P. I thought that was rather touching. :-)

According to Dr. P, these patients were the super compliant ones. They keep their appointments, the maintain their drug regimen more or less on schedule, they have a social support to help them, and they're not confrontational. All of them were on a cocktail of antiretroviral drugs. But man, are those drugs expensive! A supply of 3 pills costs about $2000 (I don't know if that's per month or per year) and this one patient was waiting for his tax return or something until he was able to pay for the next prescription refill.

It just makes me wonder how horrible it would be if these patients didn't have at least one other person - like a family member - to help take care of them, or if they weren't able to pay for their meds, or if they're unable to take their meds regularly at the specific times. That must be a nightmare. These are life-sustaining pills and if you forget to take them precisely, it could make things messy as HIV quickly develops resistance - leading to more complicated drug regimens.

Also surprising was what Dr. P told me the ages with the fastest growing incidence of HIV cases were: between 15 and 25, and older than 50. Dr. P had one 19-year-old patient who missed his appointment. That's some scary stuff, so people remember to use condoms every time!!

Oh, and the woman's test came back confirming HIV+ status. Dr. P paged every person on his team, as well as the nephrologist and a social worker. I didn't stick around to see what was going to happen, but as it is, there would be 5 people entering her room at the same time to talk with her. I hope everything went okay.
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Friday - Peds Outpatient

Okay, by now this post is long enough. This visit wasn't dramatically different than the last 2 times I shadowed my mentor so I'll keep this short.

Notably, I heard rales (crackling sound in the lungs) in one kid, and my mentor ordered a chest x-ray on her to rule out pneumonia. I was so proud of myself for actually hearing it. And I saw scarlet fever on another girl. It was pretty classic textbook scarlet fever.

There were many kids with strep infections, and I kept hoping that I don't catch it as it'd be really bad for me to get sick during exam week. Though . . . if I end up getting strep, everyone in the room with me would get infected by the end of the first exam . . . Anyway, thank God for hand sanitizers in every room.
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So that's it. I had to read through this a couple times and edit out details (so just know that it was longer still, lol). I actually really enjoyed ID, I thought it was fascinating. I still like peds though, so we'll see what happens from here.

Now to study more for my neuroscience exam on Monday . . . *Sighs*

At the Coffeehouse

We finally met! ^_^

So here's how it went down . . .

We agreed to meet at 2pm for coffee instead of a late lunch. He was coming from an appointment at the optometrist's. I finished shadowing early (I'll blog about that later), so I just lazed around in my apartment for a few hours before I left . . . time that I should've used to study (like now).

At about 1:35pm or so, I decided to leave. It only takes about 20 minutes to get there, but I had never been there and I was afraid that the monstrous highway overpass/exchange/junction would confuse my GPS. You see, just prior to entering the city from the west, there's this area where several highways join together and there are a ton of overpass bridges and exits and such (to me, it's a little more confusing than the Chicago loop - and that's saying something).

So anyway, my GPS was fine but I took wrong exits. Twice. *Sighs* That place really IS confusing. :-/ I thought I would be late, so I was kind of nervous about that. But I got there a little after 2pm. Balls it was cold outside today! It was definitely below zero (Fahrenheit) with windchill.

I enter the coffeehouse and I don't see him anywhere. The coffeehouse had this distinctly . . . hippie feel to it. Which is fine, it was rather nice. I figure I'll get my coffee first and sit down and wait for him. At this point it was already 5 minutes past 2pm. I sit down for a while, still don't see him. Then I noticed there was an upstairs area, so I go there. And I still don't see him. I go back down and sit at a table very visible from the entrance (because it was almost right by the entrance). 10 minutes later I get a call from him apologizing about how he was so late because he had lost track of time. About 5 minutes later he walks in the door, drops his stuff at my table while apologizing, and goes to buy coffee. By this time I had almost finished my coffee, lol.

This was our first time seeing each other in person. He was just as cute in person as in his Facebook pictures, lol. He had this hippie-ish look about him as well. From the way he talked and moved, I could definitely tell he's gay (and remember, my gaydar sucks). But he's not really fem . . . kind of like in between(?). After only a few minutes of chatting he remarked how I remind him of one of his friends - like a doppelganger - except that I'm Asian and his friend is Mexican. That amused me (I hope that's a good thing?).

We talked about (in no particular order): school, career ambitions, religion, medical ethics, stem cells, abortion, genetics, prostitution (commercial sex work), regenerative medicine (his interest and ultimate goal), evolution, research, treatment of lab animals, circumcision (he totally brought that up out of nowhere, o_O), TV shows, and other such things. He admitted that he smokes pot occasionally and drinks (which I'm fine with as long as he's not an alcoholic - he's not), and did drugs a couple times. But he reassured me that he wasn't a druggie or a whore or anything. I'm believe him, because it seemed like he had a rough couple years and is now working hard to turn his life around and really do something with his life. And I can totally respect that. However, I did nothing to hide my disapproval for smoking pot and drugs (though I verbally withheld my tongue). He remarked that I seemed really well-behaved and he might be a bit too much of a wild-child for me, lol. We'll see I guess . . .

He's currently working towards his Associates (I think) in nursing and has a contract to transfer to a great 4-year university for 2 more years to then complete his Bachelor's. Then he's going to apply to med school with the ultimate goal of going into regenerative medicine (not even a medical field yet really) and help people regrow tissues, limbs, and/or organs. His road is MUCH longer than mine, his ambitions higher, but I think he can make it.

Anyway, if you've gathered from some of the topics above, we had a mostly intellectual chat. I think that was mostly his doing, as he was more talkative and constantly said something like, "You don't know how great it is to have an intellectual conversation with someone - the people around me are usually stupid and I feel like I have to constantly dumb down my language." Well, he certainly doesn't have to do that with me. ;-)

He's definitely a straight-forward, in your face to-the-point kind of person; whereas I'm a more cautious and moderating person, at least in what I say out loud (or write). We talked for a good 2.5 hours or so with no awkward silences. At around 4pm I had wanted to go and at least move my car, because I parked on a side street that had a sign saying 2-hour parking limit between 7am and 7pm. Yeah, I'm a goodie goodie. Even so, we just kept talking for another hour or so, haha. It was past 5pm when we both decided to leave, mostly because we were both getting hungry (hey, I only had a banana for "lunch").

We happened to park very close to each other, so we walked into the sub-zero cold together. Once we got to our cars, we chatted for another couple minutes in the flesh-penetratingly chilly weather. Then we hugged and said our goodbyes. I must say, it felt really good to hug him for some reason.

On my way back, I got lost on the ridiculous monstrous highway overpass bridge/exchange/junction thing. Twice. This time it was my GPS's fault. And then I hit rush hour traffic. *Sighs* Fuck that, next time I'm taking local roads into the city, as it's only 3-5 minutes longer than by highway.

I realized that I had this slight smile when I got back to my apartment. Maybe that was why when I was chopping an onion, I accidentally sliced off a couple layers of epidermis on my right ring finger with the cleaver. No worries though, it wasn't a deep cut at all and there was no blood. But it's still annoying and now that finger's pretty sensitive. :-/
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So I guess I'll share my impressions of our "date."

I thought that our conversation flowed pretty well. We didn't get into any arguments, heated debates, or anything like that, but we seemed really interested in what the other person was talking about (him almost passionately so a few times). So I think we had a great chat, as evidenced by how long it actually took us to leave, lol. I think we felt pretty comfortable with each other.

I thought he's super-cute, physically. He also has a pretty cute personality in a carefree youthful way. While I obviously disapprove of the pot and drugs (which I don't think he does anymore - not that he did a lot of it in the first place), he'd have to be clueless to not be aware of it. And I think that as his education goes on, he'll be less and less likely to do such things anyway.

I don't know if I really felt a spark, but I would definitely like to get to know him more (Idk, that might be my sex drive talking - did I mention how cute he was?). He seemed like a pretty cool guy overall. Intelligent yet still "green" in many ways. Whereas his roommates are a bad influence on him, maybe I can be a good one, lol. When we parted ways, he expressed interest in getting together again later, as did I.

So yeah, this was a pretty long and detailed post. But I wanted all that in there so I can ask: what do you all think - worth pursuing further?

Due to Scheduling Difficulties . . .

Argh, why's it so hard to coordinate schedules between even just 2 people?!

I chatted with Jay for a bit last night, causing me to go to bed about 45 minutes later than I had intended. But it was worth it. :-) Here's a small snippet of our convo:

Jay: I can't wait to meet you in person
Me: oh?
Jay: our conversations online have been great
Jay: I'll bet they'll be even better in person
Me: hehe, thanks
Me: I hope so
Jay: From what I've gathered from talking with you, you're an intellectual
Me: aww, thanks
Jay: intellectual company is always favorable, lol
Me: lol
Me: there's such a thing as too intellectual
Me: just hit me if that happens
Jay: oh no
Jay: it'll probably turn me on
Jay: my 2 heads are very connected
Me: hahaha
Me: that's good to know
Jay: The brain is the sexiest organ a man can have :P
Jay: everything else is just second
Me: hehe, intelligence is certainly a good thing to have in another person
Jay: it has made finding a suitable mate very difficult

We had made tentative plans to meet this Thursday afternoon. But now he's unsure because he may/may not have some appointment. :-/ Sigh, I guess this is what happens when trying to schedule between 2 people with busy lives. I really really hope we can work something out this Thursday afternoon, as otherwise I'll be consumed with studying for my exams all next week.

Even if things don't pull through for this Thursday, I'm confident that we'll keep trying until we finally meet. The above convo has only encouraged me to keep trying. *crosses fingers*

Postponed Yet Again

I just can't seem to catch a break!! :-(

I sent Jay a Facebook message yesterday morning, just to confirm that we were indeed meeting today at noon for lunch. I figure, it's probably best to double-check just to make sure that nothing changed last minute.

Well, at around 9:30pm last night, Jay replied saying that he forgot that he had to work this morning, and so lunch would have to be canceled. I'm glad I sent that message, because otherwise he might've forgotten to tell me until this morning . . . or worse, forgot to tell me at all and leaving me there to wait for him at noon. Though he did seem sorry and did mention that he would never have stood me up, so I assume he would've let me know beforehand at some point.

I guess last night this upset me more than I thought it would. Silly me getting my hopes up. In the meantime, the clock ticks and my curse can work its magic at any moment. I hope we're able to reschedule for the near future, as we both have pretty busy schedules.

Well, if this somehow works out, Biki pointed out something quite amusing: we would have an atypical cliche doctor-nurse dating relationship, lol (but only until he gets into med school and gets his MD as well).
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On a completely unrelated note, the other night I was playing poker with some friends (and lost, as usual - I mean, I lost with 3 Kings, how does that happen?!) and we got talking about the nature of our med school class.

It seems that the "gunners" in our class don't operate in the open. The classical gunner studies at the library all the time, checks out all the books before anyone else can, finds and hoards info for him/herself, and aims to get one of the highest scores in the class. Not so in my class. The gunners in my class say they're going to go home to take a nap and unwind or something, but in reality they go home and study as the following day they know most of the material for that day already. Their secret to let no one know when they're studying, and so cast a false sense of security that doesn't cause others to go into a study frenzy.

We've aptly named these gunners "snipers." Our class is full of snipers.

I was pretty pleased when I got a 90% or so in anatomy overall last semester. However, the average was about 93%. And I was a good 5-10% below average in the other two classes (but still well above passing). FML.

Lunch Date? o_O

To those who commented on my last post, thanks for your responses.

So Jay IM'd me last night and we chatted for a bit. :-) It's interesting chatting with him. We have these moments where we seem to connect, and the convo flows freely and easily for a bit. Then suddenly it's like one of us is busy, and there are long periods of silence punctuated by short replies.

Anyway, after a while, I asked him if he was still free this weekend (and interested) for meeting up. He was. So we settled on Sunday at noon for lunch at this deli cafe place he suggested. Omg this is really happening! I don't have his number (yet), so I hope I can either get it soon or just have to count on both of us not being late or too early.

There are all these questions running through my head, pretty standard questions I'd imagine. What do I wear (as I mentally rummage through my very limited wardrobe)? How do I greet him - handshake vs. hug? Are we splitting the bill? How will the convo go? Will there be that spark, or will it be awkward/mindless small talk? What'll he think of me? What'll I think of him? Will I stutter (it happens occasionally when I'm nervous/shy)? Is this a lunch date, or is this just getting together to grab lunch and chat? Will there be more?

I hope all goes well. I feel like this is a kind of turning point - either things go forward to something more, stop at acquaintance-friendship, or sizzle to nothingness. Any thoughts/advice for me? I'm too new to this . . . *Sighs*

Thanks. ^_^

Caliber

Caliber. It's a word I've been wondering about in the last few days.

First, I'm taking this course this semester called "evidence-based medicine," or EBM for short. It's basically a crash-course on epidemiology (so right up my creek). We mostly learn about the different study designs and their inherent strengths and flaws. The idea is to make us better "consumers" of medical literature, because God knows there's a ton of bad literature that's published, even in reputable medical journals (e.g. MMR vaccine causes autism).

Anyway, my friend Aiden says things that really bugs me. He's against abortion (okay, fine, whatever), he's against embryonic stem cell research (okay . . . still fine I guess), he's against the current health care reform (he's entitled to his opinions), and he's skeptical of evolution and global warming (alas, these I can't accept). But the two statements that really make me bristle are the following:

"I'm just aiming for the lowest tier of primary care: family medicine. I don't want to compete against people for top specialties. P = MD!!"

---and---

"You know, I don't like statistics and I don't get it. So after I'm done with [EBM], I'm just going to skip all the statistical and data stuff and jump right to the conclusions and discussion sections of papers, because that's all that matters."

With respect to both, all I can ask is: Is this the true extent of your caliber as a future physician? In response to the first quote, the fact you're calling family medicine the "lowest tier of primary care" only serves to reinforce the notion of family medicine as being somehow inferior to other branches of medicine (it's not). Using that as your excuse to not try your hardest, or using that as your excuse to "only" pass, I wonder . . .

The second quote I actually alluded to briefly in an earlier post. Of the two statements, this one makes me bristle the most. Several of us looked at him when he said this and were like, "We do NOT want to ever be future patients of yours." There are so many bad papers out there that still somehow get published! The only way to really understand which are actually good is to look at the study design, methods, data collection and analysis (statistics). I mean, I seriously do fear for his future patients if all he reads of a paper are the abstract, conclusion, and discussion sections. I mean, what kind of patient care will he give if he doesn't read the medical literature fully, and ends up going along with the conclusions of a really bad study (again, e.g. MMR vaccine causes autism)? I mean, really? Seriously?

On a related note on caliber, I was talking to a friend about the kind of education we're getting here at med school as we walked to the parking lot earlier today. We both went to the same university for undergrad, and we both appreciated the kind of education we received there. Like any school, there are good and bad professors. But back in undergrad (and definitely in grad school) there were plenty of great, even amazing, professors. Many of our undergrad professors challenged us to think, not to just memorize facts or apply facts to a more difficult situation.

Here in med school there are also good and bad professors, but most are just "okay." Many of the faculty are rather old and seem pretty "stuck in their ways" insofar as how they teach and what they teach. Few present new advances in the fields they're teaching, or even attempt to make lecture interesting (and it's sooo easy to make cardiology interesting, but instead they've somehow turned me off to it). And many, being PhD's (nothing against PhD's), don't try too hard on making the material relevant to clinical care. Oftentimes they fail to answer our singular question as med students: Why should we care and how do we utilize this to help patients?

Fortunately, my EBM small-group facilitator is a doctor who makes us think about precisely that question. While reading the rather dry medical literature, she challenges us to think: "Why're we reading this? Will this help our patient? If so, how? And then what? What're the next steps for treatment?" She treats us almost as if we're on a team discussing the papers and then how to best care for a hypothetical patient. And we all really appreciate that. She does what lectures too often don't: challenge us to think critically about the material and then apply it to a patient scenario. We need more people like her teaching our courses, but alas that's probably a personality bonus more than anything else. (I still believe that all professors have to take a mandatory annual teaching workshop, because so many - wherever you are - ARE bad.)

Lastly, my roommate was shadowing his mentor the other day, a family physician. A patient came in complaining about shoulder pain. The doctor did a physical, examined heart and lung sounds, asked about family history, etc. What he forgot to do was address the shoulder pain. Just as he finished up after about 20 minutes, he asked if the patient had any questions, at which point she mentioned the shoulder pain again. Only then did he remember to examine her shoulder. Seriously?

So yeah, caliber. A word I've been musing over for the last few days - what it means, how it applies to us, and to what caliber we must hold ourselves to as future physicians and educators, as well as the caliber we hold others at. Because down the line, someone is definitely going to be depending on us or what we say, and if we're wrong . . . well, let's hope we at least did no harm.
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On a completely different note, I chatted with Jay (Online Guy) briefly yesterday. He seems so busy as he's kind of hard to get a hold of to chat online. He started classes today, so he's likely to only get busier. And we still haven't talked about the possibility of meeting this weekend for a drink/coffee. :-/

So I sent him a message on OkCupid asking about his first day of classes, and whether they're everything he hoped for. Then I asked him if he was still interested in meeting up this weekend. Lastly I gave him my cell number. Omg was that too forward?! I don't know what "protocol" is for this!! This is too new to me . . . *freaks out*

On a related note (as I've so many of these in this post, lol), a guy messaged me on OkCupid recently. He's 34, in the health care field, and hoping to finish up his R.N. degree (nursing) soon. I messaged back a couple times, out of politeness. Then today he messages me asking me if I'm free to meet up this weekend for coffee or lunch, and he gave me his number. o_O! Is he being forward? I don't know how I feel about this, but I haven't responded yet. He is 34 (a good decade older than me) . . . oh, and he doesn't have a picture on OkCupid . . . *freaks out*

Okay. *breathes*

At Your Service

This morning (Saturday) I was scheduled to volunteer at the free clinic for the uninsured run by the med students here. I was to do patient education on how to best manage chronic conditions (such as high blood pressure, diabetes, etc). Well, that wasn't what I ended up spending the vast majority of my morning doing.

Instead, I spent the vast majority of my morning translating Mandarin Chinese into English and back for this Chinese woman who spoke very little English. You know, I never fully appreciated how difficult it is to translate until now. Even though I feel I did a fairly good job translating, there were random words and phrases that eluded me - words and phrases that I know I know. Like "cancer," I know how to say "cancer" in Chinese, but it's still eluding me! Argh.

She came in with her husband who would've served as her translator, except he was called back to a different room than she was. So basically, without me it would've been near-impossible to do anything for this woman. So it felt great that I was able to help out in such a capacity. Things go really slowly when translations are necessary.

Afterwards, and after her very emphatic "thank yous" to the other med students, the doctor, and me, she asked me when I moved here from China. -_- They always ask me that, without fail. Imagine her surprise when I told her I was born in Chicago. "But your Chinese is so good! Where did you learn to speak it?" My parents speak it at home . . . so we speak it at home (is that so unusual?). Sigh, such is the curse of being an ABC.

Anywho, while I was actually doing my real role at the free clinic, I had the opportunity to talk to this diabetic woman waiting for labs to be done. She used to work at the hospital that our med school's affiliated with, until she was laid off and currently has no insurance. And here she is going to a free clinic run by med students from the med school affiliated with the hospital she was laid off from. That's some twisted irony there. But she was great about it, took it all in stride.

On a completely different note, I finally finished watching the anime Death Note today. It's sooo good!! I love the detective and scheming of it all. It's almost like a twisted kind of Sherlock Holmes (great movie, btw, if you haven't seen it yet). Now I can (hopefully) study for real . . . tomorrow that is.

That Gaydar Thing

. . . that I don't seem to have. At all (unless one is obviously flamboyant). *Sighs*

But my labmate Leslie does. She "knew" that I wasn't straight early on in our interactions in anatomy lab. Today I asked her to lunch so that I could ask her the question of how she knew I wasn't straight. Alas, she wasn't able to tell me a specific answer. Her words: on the spectrum from straight-acting to flamboyant, I'm very much on the straight-acting extreme. Well, that was hardly useful. -_- Though she seemed very confident in her ability to point out every gay guy in our class (no one is out, to my knowledge - and the medical environment isn't exactly conducive to this).

We spent a good hour or so talking about such things. We talked about how I kept my sexuality in a metaphorical box that I put on a metaphorical shelf - I know it's there, I know what it is, but I'm too scared to open it. I told her I was very uncomfortable with the bar/club scene. She mentioned internet dating (little does she know about Online Guy, lol). So we'll see what my Pandora's box has in store for me. Though I can talk rather dispassionately and at length about this online or in writing, it's sooo much more difficult in person. I was avoiding eye contact with her almost the entire time.

We also talked about how poorly the LGBTPM student group is run at our school, and that if I wanted the president position for that student organization it'd probably be mine for the taking (considering it, actually). It's almost insulting how bad it's run compared to other student groups. Granted, it's one of the smallest groups, but that's hardly an excuse.

Oh, and interestingly enough, Leslie mentioned how many gay guys develop a crush on her, thinking they love her, only to find out they're not straight later. She told me of this kid she knew in 1st grade who had a crush on her for years, only to come out in high school. Fuck, did I just fall into that pattern too?! *Sighs*

I don't know, but I think as a result, I've felt very conflicted the entire day. It's that feeling again, of an invisible hand squeezing my heart. I don't like it. I guess I'm just not comfortable with myself - not with how I look, not with how I feel. I guess I'm feeling down again.
---
Anyway, Online Guy is (apparently) busy this weekend. We've chatted a couple times online. He's more free next weekend, so we pushed meeting up back a week. I've got to come up with a name for him; I'll call him . . . Jay. And I suppose I should say a little about Jay.

He's 21, a nursing student, and has ambitions to be a doctor specifically working on regenerative medicine. He seems very liberal, pretty idealistic, and very open. He likes his beer (lol?) and admits he used to occasionally smokes pot, though not so much anymore. I don't know how I feel about this, I guess I'll seek if he reeks of it when I do finally meet him (for my sake, I certainly hope not). Intellectually we seem to have quite a bit in common.

I'm kind of nervous at the prospect of meeting him. I don't know what he'll think of me. I'm certainly not attractive (I wouldn't find me attractive anyway), so I've nothing that'd catch one's eye. I'm like an essay without a literary hook in his intro paragraph to reel the reader in, though I have the subsequent substance to make it worthwhile if one can get past the opening quickly enough.

Oh yeah, there's also an Online Guy 2 (I'll call him . . . Drew). We've only emailed back and forth on that dating site a few times. But lately his emails have been rather playful. I think he's just a laid-back and playful guy. I don't know much about him other than he's bi, 21, in his last year of undergrad, and applying to grad programs. I guess I'll see what happens with Jay first though.

---TANGENT---
So in the last few days, many of my fellow M1's who I've talked to have had thoughts of quitting med school and doing something else, like become a teacher, lol. But we all agree that we're too far in debt to back out now - there's only the way forward. I think this is mostly a function of us being really frustrated lately.

I was browsing YouTube and I came across the following two vids. To think that I was able to play the following two pieces before, insane! I was good at the piano. It's been such a long time since I was that good. It brings back memories and nostalgia.

Rachmanioff's Prelude in G minor, Op. 23, No. 5


Chopin's Sonata No. 2 in B flat minor, 1st Mvt.

This was the most difficult piano piece I've ever played - both technically and musically. Every note aches suffering, whether in rage or in despair. Thinking back, my piano teacher gave me several pieces that ached of suffering. Maybe there was something in my playing then that reflected the internal struggle I feel now. Hmm . . .

Plain White T's - 1234

I saw this posted in one of my friend's away messages. I thought it was incredibly cute. It at the same time made me both happy and sad. :-/
---END TANGENT---

It's a Long Day When

. . . you start daydreaming about sushi halfway into the first lecture of the day (out of five 1-hour lectures). And it just went downhill from there, lol.

In one of the breaks between lecture, I was talking to some fellow students and we unanimously agree: recess and nap time for med students. Seriously! Med school is rather like high school again, but please let us regress just a bit more so we can have recess and nap time, please? We'd be so much more effective and happy. :-)

I did learn something in neurobio today: effect of cannaboids (marijuana and such) = fat, dumb, and happy; calm, cool, and collected. I just found that really amusing. Actually, it's the receptors of the neuro-lipid 2-arachidonoglycerol (2-AG) that cannaboids act on. And I'm sure that last sentence meant nothing to most readers right now, so . . .

I skipped the cell & tissue bio (CTB) lab today, hoping to do it on my own time in my apartment since all the histology slides are online. But no, technology has to hate me. I'm unable to log in to my med school email as well as school-related site that requires my email name and password. The funny thing is, I save my passwords on my Firefox browser. So I went in there to make sure the password I was entering was correct. It was. AND IT STILL WOULD NOT LET ME SIGN ON.

I succumbed and just sent an email to the IT people to have my password reset so I could (hopefully) log on later tomorrow or the next day. Fortunately, I have all my med school emails forwarded to my gmail account.

In other news, "Online Guy" and I chatted a bit last night and now we're Facebook buddies, lol. He asked if I'm free this weekend to meet up for a drink. Details pending, hopes tentative.

---TANGENT---
Two things:

1. Thanks to everyone who read my last two posts and commented. Things got a bit heated I think, so I'd like to just leave those two posts alone for now and move on. I mean, my last post became so epically long! But it's not like it's going to substantially change the minds of people who're dead-set in their views.

2. Biki over at her advice blog, You Could Have It So Much Better, invited me to write a guest post. So read it here! :-P
---END TANGENT---

Re: I Guess I'll Post It . . .

First of all, I'm kind of amazed and shocked at the number of comments I did receive on my last post. I kind of assumed no one really cared because it's fairly technical and has a message that people may not agree with or don't care one way or the other. Now, before I continue with this post, I'd like to mention two things:

1. Everything, even "fact," is potentially open to interpretation. It's very difficult to present anything in such a way as to minimize the number of permutations that it can be read and interpreted. I can look at one study and its data and still remain skeptical, whereas another person (equally or more qualified) can read the same study and data and be convinced of its accuracy beyond any shadow of a doubt. I always endeavor to write my more . . . technical posts very carefully, and there should be nothing to read "between the lines." I try to limit the number of ways my words can be interpreted (or misinterpreted). That said, I acknowledge that it can still happen despite my carefulness.

2. Anon MD, did you lie to me?! If you're an epidemiologist then you must surely be Anon MD, MPH at least (if not Anon MD, PhD or Anon MD, DrPH)!! This'll be interesting. :-P

Now, on to the rest of the post.
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This post is in response to Anon MD's comments on my last post. Always the "devil's advocate" to my posts, sometimes I wonder if he's (or she's) secretly trying to pimp me. But no matter, such comments are definitely welcomed and force me to think and refine my words, and that kind of makes my brain tingle. o_O Anon MD's comments (and my responses) are as follows:

"As an epidemiologist myself, I find your comment that the fact the studies were conducted in Africa negates their applicability to the United States. Do cigarette smoking studies in England only apply to England? Absolutely not. The fact is a randomized trial confirmed the impact of circumcision. At this point, given the size of the effect, I doubt any further trials, in the US or elsewhere, would be considered ethical. It's about time those opposing circumcision (and I won't read motives into their advocacy) acknowledge that the data suggesting circumcision is protective from HIV are compelling. After all, the data are pretty compelling."

A cigarette smoking study in England applies better to the US than parts of Africa, because England and the US are more similar to each other than England and (most of) Africa. That said, smoking studies have a long history spanning decades that is verified by similar studies done in various parts of the world. So it is very well-established, and it took many years of research to effect a change.

I admit I haven't read all the African RCT papers on this subject, but I have read the Bailey et al. paper in The Lancet (2007). It reported a 60% relative risk reduction but the absolute risk reduction is 2.1%, with 25 more HIV infections in the control group (uncircumcised). Furthermore, the paper's wording leads me to believe that the intervention group (circumcised) had a "delayed start," as they were instructed to refrain from all sexual activity for 30 days rather than specifically instructing "all participants" to refrain. The intervention group also had slightly higher loss-to-followup (not statistically significant). Lastly, it's impossible to blind the participants due to the very external and visible nature of the procedure, though this is a limitation of any study of such nature.

The data may be compelling but they don't seem as compelling in a clinical setting in the US, at least not to me. In an adult man at high risk from contracting HIV via heterosexual sex (or in a high-risk country), I can understand circumcision being a consideration. But I believe that the 2.1% absolute risk reduction becomes almost vanishingly small in a country like the US, where the HIV transmission patterns via sexual intercourse is still highest amongst men who have sex with men (MSM), which numerous studies have suggested circumcision has no significant effect.

"You'll also find that many, if not most. of the things you do as a physician are backed by far less data indicating their efficacy than the data on circumcision and HIV infection. Do you plan to not practice the standard of care even if there's data to support its use? Or if the data only come from Europe, Japan, Africa, etc? I doubt it. After all, there's precious little data to show that coronary care units are efficacious, but they used in almost all cases of heart attack. If there were a trial showing the efficacy of coronary care units in Uganda, say, would you be as skeptical about the use of coronary care units in the US?"

Yes, many things in medicine don't have evidence-based medicine to back it up. It's scary that patients are even willing to put their lives in our hands with so little science to support us. That's why medicine is an art and not a science.

The issue here is that I was responding to an article advocating that US pediatricians push for routine neonatal circumcision to reduce HIV infections in a low-risk country where sexual transmission is still primarily via MSM, not an article advocating voluntary adult circumcision to specifically reduce the chances of contracting HIV via heterosexual sex in a high-risk country where condom use is abysmally low. It is one thing, ethically, to circumcise an infant who is unable to consent; it's quite another to circumcise a competent and consenting adult.

It is my personal philosophy that all surgical procedures only be performed when necessary and alternatives have either failed or don't exist. Furthermore, whenever possible, a conservative treatment plan should be preferred unless the patient him/herself desires something more radical/aggressive. I clearly won't be a great surgeon, emergency physician, or oncologist, and you may very well disagree with me. But it stands that there is no medical need to recommend/push for routine neonatal circumcision in the US. It hasn't significantly impacted STD rates in the past, and it's highly unlikely to do so in the future.

I know nothing about coronary care units, so I'll take your word for it until I learn about it. :-)

"Let's change the situation to AZT. When AZT was first available, there was less data to support its use than that for circumcision, and the data were from the US, nowhere else (and there's never been a randomized trial of AZT in Africa). AZT does nasty things to bone marrow and liver, so unlike circumcision, it has significant risks associated with its use. If you were a physician in Europe at that time, would you insist on European data before prescribing AZT for your AIDS patients? What about if you were in Africa? If you prefer, we can shift the discussion to chemotherapy for lung cancer or a variety of other conditions with prognoses similar to AIDS when AZT came out--and the risks to the patient are far greater than those of circumcision."

I believe the situation in my argument is not applicable to the AZT situation you mentioned. AZT is a treatment, not a prevention. And outlined in my belief above, in the case of HIV/AIDS or cancer, the alternative to treatment is death; so AZT (or chemotherapy for cancer) is the only route to go. I believe there were no other effective HIV drugs before AZT, so truly it was "something better than nothing." With prevention, there are often many tools available with limited funds to allocate.

The American Academy of Family Physicians (AAFP) - position reaffirmed in 2007 - cites a complication rate range of 0.1% to 35% for circumcision. I don't know about AZT, but 35% as a possible high end is really high (even if most of the complications are minor). Deaths were estimated to occur about 1 in every 500,000 operations.
-----
I hope my central argument is abundantly clear by now.

I am against routine neonatal circumcision in a country like the US where any potential positive effects are minimal at best. It's perfectly fine to offer circumcision as a possible prevention to a consenting adult at high risk of contracting HIV via heterosexual intercourse. But as far as the US is concerned, I believe that better safe sex behavior education can go much further.

Again, it's difficult to definitively say that there will not be a cure or vaccine for HIV in the next 15-20 years. So in that time, why not be conservative in this manner and leave infants as they were born? If one was circumcised as an infant and wishes he wasn't, tough luck and too late. But if a man needed/wished to be circumcised, he can always have it done. What would you say to the former individual?

---Edit 1---

"Yep, there's a MPH there, too. I'm not big on posting degrees. As for the absolute risk, you're correct, it's not that large. Then again, how large do you think the risk of lung cancer is? In absolute terms, it's not large either. That doesn't mean that one doesn't take measures to prevent it. As for a 60% risk reduction, having lived through the early years of the HIV epidemic, when the gay/bisexual viewed the advice to use condoms to prevent the spread of HIV as some sort of faschist (sp?) plot, I'll take whatever risk reduction I can get. There's a new generation of gay/bisexual men now coming into adulthood who, unfortunately, weren't even alive when HIV first struck, and many of whom one again view condoms as a heterosexual plot against them. If circumcision were to interrupt viral transmission even half as much as the African data suggest, wouldn't that be a sufficient reason to recommend circumcision in the US? Or are you willing to consign thousands who are unwilling to use condoms to becoming infected simply because of quibbles about data and concerns about the aesthetics of circumcision? I know I wouldn't. Who knows, the life that's saved may be your own."

I don't remember the absolute risk reduction for lung cancer (I assume you're talking about smokers vs. non-smokers). However, numerous studies have indicated that smoking has other detrimental health outcomes other than just lung cancer, some of which may have a higher absolute risk difference (I don't know, as I haven't looked into the numbers).

You give the example of the gay/bi male population. However, it's been repeatedly emphasized that those Africa RCT studies were only done on a male population who (as far as the researchers know) only engaged in heterosexual intercourse. And several studies (done in the US and Australia) have demonstrated no significant risk reduction in HIV rates in the gay/bi male population with regards to circumcision status. Therefore it can be assumed, for now, that circumcision confers no protective effect for MSM.

Again, I'm not opposed to an adult male who elects to get circumcised to reduce his personal risk of contracting HIV (or a health care provider recommending such an intervention for a high-risk individual, or practicing medicine in a high-risk population). That is their own personal autonomy that's to be decided between the individual and his physician.

What I do have a problem with is a blanket surgery to be pushed on all neonatal individuals of a given gender, just by the biological nature of their bodies. You may want to note that while there are mass male circumcision programs in Africa to (hopefully) reduce HIV rates, none of them are targeted to male neonates. No medical organization in the world is (or even thinking about) advocating routine neonatal circumcision, except in the US (if I'm wrong, prove me wrong with a source). What does this mean to you? Is the US somehow better/smarter/more aware than the rest of the world?

Now, there are limited funds in health care, so it must be allocated carefully. Hypothetically, let's say there's a pool of funds that go towards HIV prevention. Money going towards circumcision is necessarily taken away from money going towards condom promotion and safe sex education. In this scenario, circumcised men grow up and are less likely to use condoms because they've been told they're "protected." Meanwhile, uncircumcised men are stigmatized as being dirty, easier to infect, and are repeatedly told that they must use condoms because they're more vulnerable. What do you see as the long-term outcome? It's a very small step to from telling someone that he has a reduced risk of getting HIV because he's circumcised to that individual thinking he's "protected" from HIV and can get away with using condoms less frequently. It may already be beginning to happen in Africa, read this article.

I don't believe my views are consigning the thousands who refuse to use condoms to becoming infected. I will not stop anyone from desiring (or needing) to get circumcised himself. But the procedure does not, and personally I believe it should not, be carried out on minors without medical need or perhaps for religious reasons.

---Edit 2---

"Anon MD here. For Biki, there's an MPH and an MS, as well as a couple of other degrees. I'm surprised that matters so much to you.

As for the comments on the means of transmission, actually, in Africa, while there is a bit more male-female transmission of the virus, there is a lot of male-male transmission too. A lot of the latter are not included in anything close to a governmental document, since gay sex is illegal/heavily stigmatized in many African nations. After all, until 2 years ago, South Africa didn't even acknowledge HIV as the virus causing AIDS.

I must say that the only argument that's been put forward on this blog (and many others on this topic) is an asthetic one. No one has suggested the African studies were biased or that circumcision doesn't impact on risk of HIV transmission. The question--and it should be the only question--is whether the risks of circumcision outweigh the benefits. With all the comments given thus far, no one has put forward a viable claim that those risks do in fact outweigh the benefits. When I see/hear one of those arguments put forward, I'll comment on this topic again. In the meantime, I will refrain from further comment on this topic, and the comments are too reminiscent of the Reagan Administration's approach to HIV. Very passive. Oh, and by the way, for all the talk about condoms are a means of preventing spread of the virus (and I have no qualms with those data), take a look sometime at condom use rates among gay teens and young adults. THat's the thing about circumcision--one time, and it's there to reduce risk for life. However, if a gay teen or young adult isn't going to bother with condoms, then condoms don't do very much to reduce risk, do they?"

To address your first question, I believe both Biki and I were merely curious. If you misread that comment/question as anything more, on behalf of both of us I apologize.

For the rest of my response, I have to ask you: how carefully have you read my arguments? From your responses, I can only assume that you are quite busy (understandably) and don't have the time to read my rather lengthy and detailed responses beyond only skimming them.

Now, I hope you meant to say "female-male transmission" rather than "male-female transmission," as the study only specifically measured the former and I did not address the latter. As for male-male transmission, it's undeniable that it's occurring in Africa (just like anywhere else), but there's no data on it and it would be presumptuous to say that the African RCT studies were somehow able to measure/account for it. Again, as I've pointed out above, there have been several studies that suggest that circumcision offers no protection against contracting HIV to individuals who engage in MSM. I haven't seen one study that definitely says that circumcision (significantly) reduces HIV infection rates in the gay/bi population. If you find such a study, please let me know.

This may be an instance of misinterpretation of words, but I truly fail to see how my singular argument has been an aesthetic one (or rather that I've only had a single argument). I made no mention to aesthetics and as I prefaced this post, if I don't specifically and overtly write it, assume I'm not arguing it. Please cite sentences from my post that you felt have been argued from an aesthetic point-of-view, and I will rectify them.

As for the comment on whether anyone has suggested that the African RCT studies were biased, I believe there were a couple commenters who addressed that. Also, I did briefly mention that the patients in those studies weren't blinded (because it's impossible to do so, and this may have influenced the outcome). Furthermore, I've read that the participants in the study were all either willing or desiring to get circumcised anyway, so that seems to be potential selection bias right there - which could be a serious study design flaw. Again, I believe I've made myself clear that I don't believe circumcision will significantly impact risk of HIV transmission rates within countries such as the US.

I have also addressed the risks of circumcision in my posts (this one and last), albeit not fully. For example, meatal stenosis (I apologize for not pulling up a study) has been estimated to occur in as high as ~10% of circumcised infants. If left untreated, this can definitely become quite risky and even life-threatening. I have even read that some pediatric urologists almost specialize in correcting errors from circumcision. You may be interested to read one such account here. I can't imagine what kind of physical, emotional, and psychological pain those children and their families must endure.

As for your last point, I must reiterate that no studies have shown that circumcision makes any difference in male-male transmission of HIV. So foreskin status is irrelevant (given current data) for the gay/bi population. Your argument is insufficient. A gay teen/adult can always elect to get circumcised. I have never argued against that. But it need not be done in the neonatal/childhood period, where the individual can't consent to a medically unnecessary operation. Rather than presenting a false sense of security with circumcision, I still believe the money that would've went into funding that operation would be better utilized in condom promotion and (comprehensive) safe sex education. Has this not worked for Europe, Thailand, and now (I think) India?

I've responded to your questions point for point, when will you answer mine? :-P

I Guess I'll Post It . . .

First of all, thanks to all the people who commented on my last post. I'm glad you took the time to say something. :-) For the record, I've no intention of leaving the blogosphere any time soon.

Now I've been debating about posting the following since last night. I don't think it's really meaningful of me to post it as I doubt I'll change any minds here, but I'm going to post it anyway after talking to a couple other bloggers online. So I guess I'll post it . . .

You see, I get the AMA (American Medical Association) Morning Rounds - basically, their daily newsletter emails. Yesterday I read an article that really bugged me. So I wrote a rather involved comment in response to it, only to find out that I have to be a subscriber for my comment to be seen. Thanks a lot Wall Street Journal. -_-

Anyway, here's the "blog-friendly" version:
-----
The article:
Should Pediatricians Recommend Routine Circumcision?

My would-be comment:
"I'm rather appalled at the bias in this article, particularly from such a reputable reporting source as the WSJ.

As a former MPH (Master's in Public Health) student in epidemiology, and currently a medical student, I don't understand how people in the field can truly translate those studies to the US population. The results of those African studies haven't been replicated in the US and observational studies can be risky to base policy on.

In fact, a study sometime in 2007 found no significant protective factor between circumcision and US men. Read here.

Furthermore, a 2008 New Zealand study on birth cohorts (groups followed since birth) of circumcised and uncircumcised men found no significant difference in protecting against STIs. Read here.

Do we discredit such studies? One done in the US and the other done in New Zealand, a country whose demographics are much closer to that of the US than Africa?

And the American Cancer Society reaffirmed in 2009 that "Most experts agree that circumcision should not be recommended solely as a way to prevent penile cancer." Read here.

Also, healthy infants do die every year from circumcisions, even in Western developed countries like the US and the UK. Infants are so vulnerable to bleeding and infection immediately after birth, why would we risk their health during that time? Even if such deaths are rare, they do happen. But when they do, one must wonder, "Would this child have lived a full, healthy, and perfectly normal life had he not undergone that surgery?" The answer is most likely "Yes."

State details safety lapse at Beth Israel
Baby bled to death after circumcision, inquest said
Four year old in hospital due to messed up circumcision

Lastly, why isn't the US looking and comparing against policies from other more similar countries such as Canada, the UK, and Australia to see what their policies are and the health outcomes of their male children? Medicine isn't country-specific, and people are people everywhere you go. Social, cultural, and economic situations vary - but that makes it all the more important to compare with a population that's more similar (e.g. Canada) than dissimilar (e.g. Africa).

Statement by the British Medical Association (BMA)
Statement by the College of Physicians and Surgeons of British Columbia
Statement by the Royal Australian College of Physicians (RACP)

There are many many points I haven't even touched on, but the above should be an alarm to caution in approaching this controversial issue. I fully support the AAP's current position on the matter, neutral though it is. Until a study done in the US with a US population to definitively show that circumcision works better than, say, condoms and safe sex programs at reducing STD rates, I will remain a skeptic. Until a study like that done in Africa can be replicated in the US with just as high an efficacy, I will remain a skeptic. The former is ridiculous and the latter is unethical. So I will just say that there's no such thing as prophylactic surgery on infants and children, especially without their consent (an issue I haven't even touched on)."
-----
So think about it and feel free to comment, or even challenge and flame me (if you dare, lol). But I suspect the above words largely fall on deaf ears (or blind eyes, I suppose) of those who don't care one way or the other anyhow, or are set in their opinions.

So We've Come This Far

Today was the first day of classes for this semester. We sure hit the ground running, lol. As I was talking to some old friends over the Winter Break, I found it kind of unbelievable how far we've come.

So over the Winter Break I met up with two old friends, JR-M and JS-M. I suppose for the purposes of this (and future) post I'll refer to them as John R and Jake S, respectively. I've known both of them since elementary school; John R was my next-door neighbor for at least half of my childhood and Jake S was a good friend throughout elementary school.

I first met John R for a really late lunch. We got caught up on each other's lives a bit. For a long time I considered him one of my best friends and definitely still one of my closest friends, though physical distances between us over the years has caused some drifting apart. He graduated last year with his B.A. in communications and film studies. He wants to get into the film industry and eventually become a director one day. Alas, in this economy work is hard to come by for him. So in the mean time he's going to this "film school" to learn more about being a cameraman and such things. I hope he catches a break and gets his foot in the door, because he's one of the most creative people I know and passionate at what he does. I've read and seen some of his stuff, and I think they're quite good.

He also updated me on one of his older brothers (he has 2), Tom R. So Tom R also graduated last year (I think) with his degree in public policy, and is currently working in some kind of social work with their mom. He doesn't really like it anymore, lol. He wants to get into public administration of some kind. He'll probably continue working for a couple years before going back to school for his Master's in some program.

The following day, I met Jake S for yet another late lunch. We had gone to the same elementary school and middle school, before I moved. Then we met up again briefly in high school. We ended up going to the same university for undergrad, though it was such a large place that we never got to hang out much - a little bit freshman year as he lived in the dorm across the street from mine. He's currently a first-year dental student back at my alma mater. He's looking to go into oral surgery or something. He also updated me on some other old friends from our hometown - several people are in med school or will be entering med school next year.

My dad commented how our little 4th grade soccer team has come quite far. Several of us had played soccer together in elementary school - Tom R, Jake S, others and me. A few of us are on the med school track, Jake S is on the dentistry track, and Tom R in public policy. It's pretty impressive I must say. We each arrived at our destinations through very different routes and at different times and places. One day I'll call these old friends my colleagues as well. We're growing up. ::shudders::
-----
All this introspection has me wondering. I've come this far in blogging. This year my blog would turn 3. Woah, that's like the Methuselah of blogs! I mean, Courage of A Beautiful Addiction is leaving, Mirrorboy of Mirrorboy's Blog is leaving, and Jay of Sun in my Face is already gone without so much as a goodbye!!

So I wonder, now that I've come this far, how much farther is there to walk? How much longer will I be blogging? Do all blogs have a "shelf life" as it were? I wonder if mine's nearing its expiration date. And if so, what then? It's not as though I feel like I've made any critical contributes to the blogosphere, which is fine as it wasn't my original intention anyway. And it's not like many people would miss me (though there are a handful of you out there, I'm sure).

Food for thought. No plans of closing my blog as of yet. But I do wonder what direction (if any) I want to take this blog in 2010. And most other blogs as old as mine are already long gone. Hmmm.