A Difference in Philosphy

A few days ago, several of us got together for wine and cheese tasting and we decided to hang out afterwards.  There was a teacher, a surgeon, a pediatrician, and an MD/PhD in training.  Much of the evening was wrapped in very heated debate, from gun control, to "Obamacare," and to education.

At the heart of the debate is a difference in philosophy, not dissimilar to democrats vs republicans.  It is no secret that education in the US is in need of an update.  The question is, how to best remake the education system in the US?

On one side is the surgeon, utilizing a surgeon's thinking.  The argument: We should focus our resources on those who can best utilize them and elevate those students to their maximum potential, and not "waste" resources on the students at the bottom who cannot demonstrate improvement.  Society should strive to equip the best and brightest with the means to achieve what they're meant to.  This makes sense in a surgeon's mind, as a surgeon must be able to triage which patients are suitable for surgery and which aren't.

On the other side is the teacher and (peripherally) the pediatrician.  The argument: We provide all students the necessary resources to succeed - for the bottom of the class to reach the middle, and for the best and brightest to soar.  Every child in society deserves a fair shot at an education, with resources devoted to the struggling as well as to the gifted.

The problem with the first argument is that it is in danger of creating a tiered caste society, only widening the achievement gap into a chasm.  The problem with the second argument is that there simply aren't enough resources or political will to make it a reality everywhere.

My personal issue with the first argument is that I believe that all children deserve a fair shot, not just some.  And yes, some children need more help and resources to achieve, but it is possible.  I have seen it.  I have worked with a charter school that - rather takes the best of the best students - takes the worst students in public schools and demonstrates that they can at least achieve to the middle.  These are students who dropped out of school due to LGBTQ bullying, teen pregnancy, domestic violence, mild mental health issues, etc.  Given the right learning environment, they are not hopeless.

On a more personal note, I have a good friend growing up who went to the same schools as me for most of our K-12 lives.  I was almost always in the honors/AP courses.  He was barely scraping by in the regular courses.  His educational experience was vastly different than mine.  My teachers expected us to push hard and succeed.  His teachers treated him as though he could not achieve and would never amount to anything much more, that learning wasn't as important for him.  This negatively impacted him until he had a moment where he was determined to change his fate.  He transitioned from a 2-year college to a 4-year state university, and from there got a good stable job helping others in bad social situations.  He was able to succeed.  Is he the next Steve Jobs or Bill Gates?  No.  But neither am I.

The reality of the current status in education is neither - currently the system is more and more being set up to "teach to the test," thereby aiming to bring the bottom up but also inadvertently bringing the top down, both meeting in the middle.  Critical courses such as creative expression (art, music, theater, etc) and physical activity (gym, recess) are being cut out in order to cram more math and science to satisfy the tests (and I'd argue that science isn't even being taught properly on the whole).  Current education is trending towards mediocrity as more tests are implemented to demonstrate achievement and teachers are being paid for performance (an oversimplification and generalization, but I'm not in education so this is just what I hear).

I don't know the answer to "fixing" the system, just as I don't know the answer to fixing healthcare.  Obamacare is one answer, but I'm not convinced it's the best or final answer.  The alternatives aren't much better though.  What I do know is that the answer depends on the philosophy we choose to take, both on a personal level and as a society.  Are only some worthy of the resources?  Do everyone get the exact same resources?  Or is the answer more nuanced?  I don't know but I do know that the answer is a difference in philosophy.

To Be Wanted . . .

It's such a weird feeling (for me) to be wanted.

What I'm most caught off-guard by during these residency interviews is just how much the program wants me (I suppose that makes sense, otherwise they wouldn't invite me for an interview).  Still, I'm left awkwardly speechless when an interviewer enumerates the various things I've done in med school and react amazed when I describe them.  It's almost embarrassing.

Up until now I've received little recognition outside my circle of friends and faculty advisors for the things I've done.  Everything I've done felt like it was being quietly conducted in the shadows outside the glowing praise of my institution at large.  I never received an award or anything of that sort, and I doubt I ever will - I simply don't have the overwhelming popularity to bring visibility to the things I champion.

But at almost every interview I've been asked to describe (in some detail) the community advocacy work I've done for the Asian and LGBT communities.  Some interviewers are more keen on hearing about the health literacy project I did in the Asian-American community, others are eager to hear about the cultural competency training I forwarded in LGBT health education, and still some want to hear about my involvement on a state policy level.

At one of my recent interviews, my interviewer asked me, "How are you able to do all this?"  And I began to reply that I was lucky and these opportunities fell into my lap in such a way that I couldn't turn them down.  He cut me off and corrected me that I instead "seized the opportunities."  I never thought of it that way, but I suppose he's right.

As these interviews wind to a close, I'm more and more certain of what I bring to a residency program.  This wasn't crystal clear at the beginning, but now I know.  Programs didn't choose me because of my grades or Step 1 score (verily, I'm positive that many programs rejected me based on those criteria), but rather the extensive community outreach and advocacy work I've done.  I'm glad that the 11 places that chose to interview me saw beyond the numbers to something more important that I can bring.

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P.S. For anyone applying to residency programs, everything you write in your ERAS application is fair game for interviewers to ask you about - and they will ask you about them, so know your application stone cold.

Treatise on a Cultural Truth

The Truth by ~-nightm4r3- on deviantART

I wish to begin a discourse, a treatise, on a cultural truth.  That what we believe is true, correct, and accurate may not hold true across all peoples.  Given the same data and knowledge, we may reach very different conclusions - each with its own merits.  Warning: this post is rather long.

Early last week, the American Academy of Pediatrics (AAP) revised their position on infant male circumcision, stating:

"New scientific evidence shows the health benefits of newborn male circumcision outweigh the risks of the procedure, but the benefits are not great enough to recommend routine circumcision for all newborn boys."

It is a shift from the AAP's neutral stance that had been reaffirmed since 1999.  The statement was revised by a committee that had reviewed the medical literature on the subject for the past decade.  This is in stark contrast to a German court in Cologne that essentially banned non-medically indicated circumcision, and you can read my thoughts in my post here.  To me this contrast highlights one of the age-old questions: "What is truth?"  Is truth objective or subjective?  Is it an immutable reality or something malleable to our perspectives?

The BBC News wrote a nicely balanced article, Circumcision, the ultimate parenting dilemma, comparing and contrasting how the US and Europe have approached this topic, looking at the same medical literature, and coming to polar conclusions.  Whereas the AAP has move more "pro-circumcision," the Royal Dutch Medical Association maintains its neutrality (if not slightly "anti-circumcision") stance.  At the end of the day, despite the science and the medicine, it would appear that the decision is decided upon a cultural truth.

Around the same time as the AAP's new guidelines, Dr. Tobian et al. - the same Dr. Tobian of Johns Hopkins who conducted one of the African trials that linked circumcision status to lower HIV infection rate - released an article titled: "Costs and Effectiveness of Neonatal Male Circumcision."  Instantly news stations ate up that press release, with news titles such as:

LA Times: As circumcision declines, health costs will go up, study says

AFP News: Fewer circumcisions could cost the US billions: study

TIME: If circumcision rates keep falling, health costs and infections will spike

CNN: Decline in circumcisions could cost billions

All worded rather strongly with words such as "will go up" or "will spike," suggesting an objective immutable truth to the study.  So what did the study report?  It says that if the US infant male circumcision rate continues to fall and fell to 10% (the approximate rate in Europe), the following could occur:

Lifetime health care costs per man: increase by $407

Lifetime health care costs per woman: increase by $43

Net expenditure for the US health care system per year: increase by $505 million, reflecting an increase of $313 per male circumcision not done

Net expenditure for the US health care system over 10 years: increase by over $4.4 billion

Lifetime prevalence of HIV for men: increase by 12.2%

Lifetime prevalence of HPV for men: increase by 29.1%

Lifetime prevalence of HSV-2 for men: increase by 19.8%

Lifetime prevalence of Infant urinary tract infections (UTIs) for men: increase by 211.8%

Lifetime prevalence of bacterial vaginosis for women: increase by 51.2%
Lifetime prevalence of trichomoniasis for women: increase by 51.2%
Lifetime prevalence of HPV for women: 12.9-18.3%

Those are big numbers, fighting numbers.  But they are potentially misleading numbers.  First of all the calculations based off of prevalence is, in my opinion, disingenuous.  Prevalence is the total number of people in the population with the disease at a given time.  The incidence rate is the number of new people contracting the disease within a time period.  The prevalence for a disease such as HIV, HPV (genital warts or cervical/anal cancer), or HSV-2 (herpes) will always be higher than the incidence rate.  Why?  Because people are living longer with those diseases, and they're considered "chronic," so the prevalence will always increase even if the incidence rate falls.

Second, the study fails to compare/contrast incidence rates between the US and Europe.  It instead falls on relying on data from the African trails on HIV and other sexually transmitted infections (STIs).  When Tobian was interviewed and asked about comparing the US to Europe, the article states:

"It is too difficult a comparison because "we have very different racial and socioeconomic backgrounds and different transmission dynamics," he said."

Wait a second there.  Tobian et al. used data from Africa, where racial and socioeconomic backgrounds and transmission dynamics are clearly more different compared to the US than Europe compared to the US.  Didn't he just invalidate his study, in some sense?  So what is the comparison between the US and Europe?

Utilizing the European Centers for Disease Prevention and Control (ECDC) and the US Centers for Disease Prevention and Control (CDC) data, we can see the following:

Chlamydia:

Europe (overall): 143 cases per 100,000 people (2000) to 332 cases per 100,000 people (2009)

US: 405.3 cases per 100,000 people (2009) to 426 cases per 100,000 people (2010)

Gonorrhea:

Europe (overall): 16.8 cases per 100,000 people (2000) to 11.7 cases per 100,000 people (2009)

US: 98.1 cases per 100,000 people (2009) to 100.8 cases per 100,000 people (2010)

HIV:

Europe (overall): 6.6 cases per 100,000 (2004) to 7.8 cases per 100,000 (2010)

US: 16.3 cases per 100,000 (2010) - CDC's website wasn't too user-friendly for finding info

HPV and herpes aren't tracked as closely and are difficult to track because of a latent asymptomatic phase.  But the US CDC cases seem to be overall steadily trending up, though herpes appears to actually have had a steep decline in the past 2-3 years.

As you can see, the US has higher incidence rates of all STIs, including HIV, compared to Europe.  At first glance, most of the STI rates in the US are either stable or slowly trending up at a rather consistent pace since the 1960s or so.  As infant male circumcision rates have decreased since the 1980s, one would expect to see a quicker pace of increase starting in about 1995-2000 or so (when the first cohort of more uncircumcised males reached age 15 or so).

It's true that Tobian et al.'s study is true utilizing the data he used.  But with additional data, different data, I reached a different truth.  What I see is that:

1. the rates of STIs in Europe (on the whole, individual countries vary) are lower than in the US - and we should figure out why before resorting to cutting off a part of the human body.
2. the velocity of increase in rates of STIs in the US aren't speeding up as the years progress, which should theoretically correspond to a decrease in infant male circumcision rates over the last 30-40 years if Tobian's assertion is correct.
3. despite an estimated 211.8% increase in male UTIs in Tobian et al.'s study, the rate of UTIs in baby boys is still at about 1% or less (a lower rate than for females at any age).
4. despite an estimated increase in HPV among both men and women in Tobian et al.'s study, there is now a vaccine for HPV that he likely didn't factor in (a vaccine, might I add, that has been recently FDA-approved for use in men as well).

So we must sometimes evaluate what we deem as "truth."  Even if we look at the same object we may still see it differently.  Culture can shape our truths and to evaluate our truths we must sometimes not evaluate the data, the science, the medicine, but rather the culture with which those truths are framed.  Below are some well-written challenges against the culture truth of infant male circumcision in the US:

Our Bodies, Our Choice: Circumcision is Not a Joke

Why Do We Still Circumcise Boys?

Why I Didn't Circumcision My Sons

The First Lady with Grace

I just got done watching the first night of the 2012 National Democratic Convention.  I was floored by Michelle Obama's speech bringing the first night to a close.  I'm also rather floored that it's already posted in its entirety on YouTube for you all to replay.

I believe it connected with many Americans in a very personal way.  It highlighted the struggles to improve one's station in life and that though it may not be realized in one's own life, it can happen through one's children or one's children's children.  It's not dissimilar to the story of my own family, immigrating from Hong Kong in search of a better life.  How my mom's family lived together in one apartment and I was cared for by all family members when I was born.  How my parents, grandparents, and uncles began on food stamps.  How my family worked its butt off to allow me, my brothers, and my cousins to be where we are today.

She tactfully touched upon all the social issues that President Obama has in some way championed - women's rights, healthcare reform, gay rights and marriage, and support for veterans.  She humanized him in a way that only she would be able to do.  She gracefully didn't lampoon the Republicans, something very refreshing to see.  It's easy to see why she's the most popular woman in the US.

I do agree with the news commentator on the TV - the Democrats have the social issues in hand, lock and step, but they need to refocus a good portion of the remaining nights of the Convention on the economic issues.  True, the economy has recovered and is growing, albeit slowly.  But they still need to bring that to the forefront.

When the Courts Intervene

These days the news are filled with stories of various laws, bills, and practices brought before the Courts system.  It must be difficult to be a judge, to sit in a position of logic when so many of the arguments brought forth are ones of emotion.  And when it may at first appear that the Courts overstep their boundaries, the reaction can be explosive.

In Germany, a curious ruling was made by a Cologne court: German Ruling Against Circumcising Boys Draws Criticism.  Of course Jews and Muslims are up in arms over this, believing the court overstepped its jurisdiction and invaded religious space.  The court basically ruled (paraphrased) that the child has the fundamental right to bodily integrity and must be able to consent to the procedure if it's not done for medically indicated reasons.  It sounds logical enough.

Now the vast majority of circumcisions are done in infancy or early childhood, when the child cannot of course consent.  By Jewish tradition it happens on the 8th day of life.  Muslim tradition, as I understand it, varies a bit - it could be in infancy or all the way in adolescence (when the child would be able to consent).

So the argument come back, does the child's fundamental right to bodily integrity trump the parents' rights to parent?  To dictate the child's religion?  This is a gray zone, to be sure, and I'm not sure why male circumcision gets such a pass (from a logical standpoint).  Courts have ruled previously that a parent may not tattoo their child.  Courts have ruled that female circumcision (aka female genital cutting/mutilation or FGM) is illegal.  Are those necessarily drastically different?  Tattooing inflicts a permanent mark on the child, but doesn't remove any part of his/her body.  Female circumcision exists on a spectrum - the most "benign" being a simple prick to draw blood from the clitoral hood (or removal of the clitoral hood) to practices way more extreme.

One medical body considered allowing physicians to perform the most benign on the FGM spectrum (pricking the clitoral hood to draw a few drops of blood, symbolically of female circumcision) to assuage parents who come from a culture that practices that, and to ensure they don't take their baby girls to a practitioner who'd do something way more extreme.  That consideration was met with a furious backlash and promptly retracted.  But we're allowed to do more than that to baby boys.  I mean, really now?

For the purposes of this post I'm ignoring the potential medical benefits/risks of male circumcision because the research on that waffles all the time, and whatever potential medical benefits that may be gained are easily achieved with other means (e.g. using a condom, good hygiene, etc).  But these procedures, because they are surgical in nature, do come with very real risks.  In an old Jewish tradition (fortunately not practiced by most - I think - Jews these days), the mohel sucks the blood away from the circumcision wound with his mouth.  This is obviously not sanitary and is against all medical standards.  How 11 New York City Babies Contracted Herpes Through Circumcision.  That's one of the complications of that particular practice.  Now in normal healthy older children and adults, herpes is annoying but nothing more really.  In babies, because their immune systems are next to none, a herpes infection can be deadly.

And when public health officials try to intervene to limit/stop these practices, religious backlash is again furious as they claim they can self-regulate.  Clearly not always.  Circumcision, as my ob/gyn attending once said, has a "narrow therapeutic window."  It's not a difficult procedure to perform, but when you mess up, you mess up big time and you can destroy that kid's life.  That's not a burden I'd like to carry.

If at this point you may think I'm bashing religion, I assure you I'm not.  But when a religion requires modification to a person's body, particularly to a person who cannot consent, there are at least standards that must be met.  I'm in full support of medical/public health/legal bodies regulating such practices to ensure minimal harm.  The Cologne court in Germany may have gone too far, but the issue they bring up is valid: does the parents' rights trump the child's right to bodily integrity?  What if the child grew up and wish he (or she) wasn't circumcised?  What consolation is there then?

On my ob/gyn rotation I met a young first-time mother who asked me, as she was in the last stages of labor, whether her son would get circumcised right after birth.  I tried my best to mask my shock.  I said that the baby must first be observed for at least 12+ hours to ensure he's healthy enough.  I told her if she wished it to be done, it'd happen the following morning.  She asked me again if it'd be done right after he was born.  I reiterated myself.  Her friend suggested she could just leave him uncircumcised, that there's nothing wrong with that - I agreed and said most of the world's men are uncircumcised and the vast majority of them have no health problems because of it.  She considered this for a full 3 seconds before asking me that question again.  I changed the topic, exchanged some polite words, and left.  This mother, in my opinion, shouldn't have had the right to make that snap decision for her son without full consideration of the potential risks/benefits.

Thoughts?  Should logic rule over emotion and tradition?  Did that German court go too far, or simply conform to laws regarding other somewhat similar practices?  Whose rights should respected first?

Here's one last article, food for thought: Circumcision's Deadly Fault Line: Rationality vs. the Metzitzah B'Peh.

The Truth of the Matter

About a week ago, I was having lunch with some friends (most of them in med school with me). I can't recall how, but we arrived on the topic of "conventional" vs "alternative" medicine.

We had all read at least some excerpt of Anne Fadiman's book, The Spirit Catches You And You Fall Down. It's a biography of a Hmong girl who develops seizures and about the divide between Hmong culture and and Western medicine culture. Interestingly, my friend and I took away very different messages from the book.

He cited a quote from a surgeon towards the end of the book saying to the effect, "Western medicine works" and claims Fadiman ignores that fact and moves on. He believed that all of the alternative medicine and cultural beliefs of the Hmong in the book were essentially crap and that Western medicine was the one true solution to the girl's seizures, and that everything else got in the way. Western medicine is the only thing that works. I disagreed on two points: 1.) it doesn't really matter if Western medicine is superior or not if the patient doesn't want to take it, 2.) not all alternative medicine is necessarily crap - a lot is just unproven medicine.
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1. The truth of the matter is, patients don't always think highly of doctors. It's our fault, really. Doctors can be so dismissive and so readily "reduce" patients to numbers, diseases, and organs. We can appear cold and disengaged. It doesn't matter if Western medicine is the only thing that works - if patients don't take the medicine we give them, the effect of our medicine is zero. We must negotiate without patients, we must compromise with our patients, we must work with our patients to get them the best medical care possible.

There's a great article written on KevinMD.com (a great medicine/health blog) titled, Stop the Us versus Them mentality in medicine, that speaks very well to this point.

2. The truth of the matter is, not all alternative medicine is crap. A little over decade ago, acupuncture was scoffed at as a sham and now it's routinely used as an adjunct to treat pain and some other conditions. Though the research on acupuncture can be argued as not being the most rigorous and powerful out there, it did demonstrate real potential. Garlic has some medicinal properties and so does St. John's wort.

Herbal medicines and teas can augment or interfere with the effects of our conventional drugs. It behooves us to know what these herbals may do, so we may advise patients accordingly. More research needs to be done. There a lot more alternative medicine out there than research is able to elucidate its true effects. There's a lot of untapped potential that needs to be refined into a product that can reliably and safely work - to disregard it all as "for hippies" or "essentially placebo" is a disservice to patients and the spirit of science and medicine.
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Another friend at lunch remarked, "Do you know what alternative medicine that's proven to work is called? Medicine." I disagree somewhat. There's a difference between the word "alternative" and "integrative and complementary." Not too long ago research showed that a tablespoon of honey in a cup of hot water helped temporarily relieve symptoms of sore throat and cough. But these things alone usually can't suffice, and hence are integrative and complementary. Alternative implies a divergence from conventional medicine.

This article, The Believers, that my friend sent me yesterday unsettles me a little. It may seem hypocritical of me to say that, given what I've argued above. But I am by training a scientist. I acknowledge that there is a world outside what research has touched (because if research has touched it all, there would be no further research). I believe that many alternative therapies warrant further scientific research to see if it truly works or not.

Anyway, the truth of the matter is, we shouldn't dismiss alternative medicine so readily because we don't always have proof it doesn't work. Also, if we dismiss it so readily, patients may take offense and refuse to take the medicines we prescribe. And if they don't take our medicines, that have research backing that they work, then what's the end effect? Oh yeah, nothing.

Mask of Ideas

i used to have great ideas by *Formor on deviantART

"We are told to remember the idea, not the man, because a man can fail. He can be caught. He can be killed and forgotten. But four hundred years later an idea can still change the world. I've witnessed firsthand the power of ideas. I've seen people kill in the name of them; and die defending them."

I just watched V for Vendetta (finally) last night. It's definitely one of the best movies I've seen. I can't believe it's taken me this long to watch it! I love the premise of the movie. That an idea can be so powerful and consuming is certainly thought-provoking.

And so I ask: what was the last idea that you felt was worth fighting for? The last idea that was worth risking something for? Sacrificing something for?

While there are few ideas of mine that involve much risk, ideas have been consuming my time of late. Before this year, I never considered myself an advocate of much. There were few ideas that I felt passionate about to actively champion. But here I am, advocating for change and improvement. That ideas can be so enrapturing and form a mask is very real.

As I may have alluded to in the last few posts (or maybe not, I don't know), the idea of "diversity" has become my cause. Diversity competency has been slipping from the medical curriculum here, and that's not a good thing. It's such an easy thing to cut since with advances in medicine, there's more to learn and as they saying goes, "Something's gotta give." But as the patient population becomes more diverse, we must be keeping pace with being comfortable and competent to treat any patient that walks through our doors. As such, I've been working with the Office of Diversity, with the student Diversity Committee, with other students in the AMA (American Medical Association) to push for resolutions in the state medical society, and within my own student organizations.

And I never imagined I'd be doing what I am now, that this would be my idea and cause. I always thought that someone else with greater passion than I would take care of it. Clearly it hasn't been done, and so I step up.

But in that same quote above, follows the next line:

"But you cannot kiss an idea, cannot touch it or hold it. Ideas do not bleed, it cannot feel pain, and it does not love."

And this makes me wonder. What am I missing/sacrificing? That line rings true. I can't kiss, touch, or hold my ideas. They're intangible thoughts and only their actions can be become manifest, not them themselves. And sadly, I haven't experienced this thing known as "romantic love." I don't really know how to go about it. I run into walls and barriers every time I try. Have I, perhaps, diverted that energy towards an idea/cause bigger than myself instead? Who knows.

And coming back from school today, I thought to myself: what is the idea behind our white coats? What does it mean and symbolize? All I see is something that gets dirty incredibly easily but fortunately has a ton of utility (in its many pockets). The white coat doesn't make me better or smarter than anyone else, I am no different, it doesn't make me impervious to anything, so is there an idea behind there that I can rally behind?

Because you see, in pediatrics, few people (residents and beyond) wear their white coats and they often seem relieved to not have to . . .

Such existential questions behind this mask.

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*

Mask of Medicine

It's curious that I've been talking about my adventures in med school a lot recently (most of my posts since August), and yet I've failed to explicitly discuss the Mask of Medicine that practically all med students, residents, and doctors wear. Unlike my other Masks, this Mask has some physical manifestations as a white coat, scrubs, and/or stethoscope.

This is a Mask that trumps all other Masks. When it's worn, next to nothing else matters. Time melts away, personal dramas are set aside, and you push through drowsiness and exhaustion - all that matters is that person in front of you. To say, "How can I help you?" or "What brings you in today?" and have a total stranger tell you some of his most intimate details of his life, to place his trust in you, how can you even dare think about anything else but that person in that very moment? All you care about, all you should care about, is helping that person the best you can. And when you do your best and you know that, you feel a distinct sense of achievement.

I'll be the first to admit I'm not the best med student in the class, book-wise. Heck, even with a 95% on one of my last exams I was still below average (or that my 82% on another exam is below the average of 89%)!! Nothing stings more than knowing that, though you've passed and actually did quite well, many many more students did better yet. But medicine is so much more than book smarts, so much more than memorizing pathways and facts. And so far I've taken consolation in that.

There are students who fail so badly at medical interviewing that you pray they decide to go into radiology or pathology, where they never have to see patients face-to-face (or at least, not much). There are students who desire to do the least amount of work possible and aim for the "lowest tier" of medicine. And there are many who scoff at evidence-based medicine (EBM) - who scoff at epidemiological study designs, biostatistics, and valuable critical thinking and analytical skills. I have a friend who feels he'll be too busy to read medical literature when he becomes a practicing doctor, saying he'll only read the abstract and the conclusions of the studies and base his judgments on that; I worry for his future patients.

And then I realize that at the heart of the Mask of Medicine is an extension and amplification of the Mask of Caring. My roommate accuses me of "thinking too much" about medicine, about the issues that we may face in the future in clinical care (then again, he's just a bum). That I think about how I can better improve how I interact with patients; about how the ability to read, interpret, and critically evaluate medical literature is more important than any amount of biochem learned throughout a single semester; about how important cultural awareness is when dealing with a population as diverse as the US; about how "unfriendly" most medical practices are to LGBT persons (mostly unintentional); and about how we can all personally improve how we conduct care - perhaps I do think too much . . . perhaps I do care too much. I'm not saying I'm the best med student to grace the clinics - far from it. If there's anything this Masks shows me, it's that I've a long long way to improve in all respects.

The Mask of Medicine is all-consuming, it often dominates the majority of my days. Medicine, as preached to me by every physician I've spoken to candidly, is more than a job. The doctors who treat medicine as "just a job" are not good doctors and are rarely happy being doctors. This Mask is an exhausting one, but often also a rewarding one.

---TANGENT---
Last night I watched a gay-themed movie called Eating Out 3. It's a rather silly film - a bit over-the-top, but also hilarious and had some pretty hot scenes. Interestingly, all 6 of the main male characters are gay, and read an interview with them here. One of the main characters, played by Chris Salvatore, is simply gorgeous:

He's also a singer/songwriter with his own myspace and YouTube pages. I listened to some of the songs at those 2 sites, and actually liked some of them. So head over and listen to some tunes. And watch the movie if you're feeling up for a laugh and maybe a couple "awww" moments.
---END TANGENT---

To: Anonymous (Doctor)

Yesterday I received a series of comments on my post from a doctor as Anonymous. I will refer to Anonymous doctor as AD in this post. AD, I hope you read this post and my response to your comments.

First and foremost, I am surprised and very appreciative that you have taken the time to comment on my blog. I understand that, as a practicing physician, you must be very busy and thus I thank you for taking time to contribute your insights and thoughts. I will re-post your comments below before I respond:

OK, I've refrained from commenting in the past, but I simply have to do so now.

I'm a physician, in practice. I understand your skepticism at the biochemical info, but like it or not, you will use it--more often than you can imagine. Especially once you're out of medical school. I suggest you learn it well now, because you will never again have the kind of time you now have to do so.

As for the inheritance patterns and the like, you won't know enough medicine to be able to understand such material until you're almost through your second year. Some schools start teaching this stuff in first year, but it's most schools' experience that few student can assimilate the information until they have a fair bit of pathology under their belts. For example, there's a lot more to sickle cell than just that the cells sickle in hypoxic conditions. No doubt, you'll argue that statistics isn't worth your time either, and epidemiology is a bore--though it will determine much if not most of how you will practice and be compensated. The pharmacology course won't cover drugs, because you really can not learn them until you're on the wards and in the clinic. I think U of Penn tried to bring drugs into pharmacology several years ago for about 3 classes, and it was little short of a disaster. As for why few med students go into genetics, it isn't a function of the way the material is taught. (Don't believe me if you don't want to, but that's the reality. Choice of speciality is entirely personality driven.)

As for Gross, ancient is good. Those are the folks who really know the material cold. And that's what you need during the dissection. As for the formaldehyde, you will survive. Everyone does. And it beats being exposed to some undiagnosed virus, which is the alternative.

The dissection may seem inhuman (and inhumane), but the reality is that the first step of becoming a physician is learning to detach yourself from your patients. Empathy is good, for sure, but unless one can objectively assess what's going on in a given situation, one is set up for failure as a physician. As you assemble the "pieces" back together when you get to the wards, you'll begin to look at your patients as people, but you'll also be able to take a step and figure out what's going on with them in a dispassionate way. That may sound cruel or like gobbly-gook, but it is what happens, either in medical school or, for some, during their internship. And it DOES happen.

And if you really think I'm full of it and have absolutely no idea what I'm talking about (and I remember thinking exactly the same as you), go volunteer as a med student in the ER for a weekend, or even just a Friday or Saturday night (as in when the Knife and Gun Club has its meetings/activities). Objective observation is often critical for saving someone's life, or at least making certain that nothing has been missed.

Enjoy this year. You'll never have the opportunity to learn this material the way you do now. Though I wouldn't want to go through med school again (three relationships lost in the first year alone), I'd do a lot to have the opportunity to learn that material again.

Oh, and with regard to the wasted info they're making you learn, hey, 50% of what you learn in med school will be out of date if not outrightly wrong within 5 years of your graduation. Which 50%? That's something no one knows.

Oh, one more thing--memorize the brachial plexus. It seems stupid to do so, but that shake one of your classmates' hands and ask them to pretend they lost innervation (through a lesion of the plexus) of one or two specific muscles. Then use what you memorized to figure out where the injury took place. Even with CT scans, knowing how to diagnose a neural injury based on simple things like where an injury took place in the plexus is quite important.

There are several things I would like to address and clarify. My aim is to neither challenge nor dismiss your views, as it is very valuable to me to have someone who's "been there done that" to comment. I would simply like to elaborate where I am coming from.

Our genetics course here is only 3-4 weeks long. Then it switches over to biochem for the remainder of the semester (until December). I fully understand and appreciate the importance of biochem, but in these precious 3-4 weeks I expected to learn genetics and not biochem, as I know biochem will shortly follow anyway. This has not happened. As far as "true genetics" (e.g. the inheritance patterns, genetic diseases, ELSI issues, etc) material goes, I have learned more in high school and undergrad compared to this course. It is my opinion that throughout my medical education there will never again come a point where the opportunity to learn about diseases from a purely genetics point-of-view will occur. To me, this (mini-)course is a missed opportunity to prime and sensitize med students to the emergent importance of genetics in medicine.

I do not believe a complete understanding of pathology is necessarily required in order to highlight the genetic components of diseases. I've taken courses before that have delved quite deeply into the genetics of sickle-cell anemia and Huntington's corea without more than the most basic understanding of their pathology. Pathology comes later to flesh out the details of diagnosis.

With respect to statistics and epidemiology, I was a grad student in Hospital & Molecular Epidemiology for a year before starting med school. Therefore I fully appreciate the importance and relevance of these subjects to clinical medicine. I am actually somewhat disappointed that my med school curriculum does not do much more than mention the most superficial aspects of these subjects. They are critical to evidence-based medicine and understanding the literature, so that each physician may make a critical judgment and opinion about whether the evidence is strong enough to affect his/her practice.

Back to the topic of genetics, in several of my public health courses, we had discussed at length the lack of genetics understanding most physicians possess and/or how they are learning/focusing on the "wrong" material. My genetic counseling friends lament how (many) doctors are not able to recognize what is a genetic disorder and what is not (especially with prenatal and pediatric genetic conditions), or attempt to order a genetic test without being able to understand the results. Many in my courses feel that physicians seem to dismiss the emergent importance of genetics in medicine, especially with the "promise" of personalized medicine on the horizon.

I do not know what to expect in regards to pharmacology. I will not take that course until next year. My friend at Case Western has lamented to me how she had to memorize a list of pain medications, blood pressure medications, and cholesterol medications (at the very least, the major name brands). I understand that each med school has a different way of teaching the same material, and when the time comes, I will likely call my pharmacy friend and ask her for help when studying pharmacology. Because that's what pharmacists are for (and she's pre-agreed to this). :)

While I agree with you that choice of specialty is personality-driven, I also believe it is also in part exposure to the field. Not many med students (that I've spoken to) know that medical genetics is an option. Other more "obscure" specialties (e.g. infectious disease, community health) aren't very well highlighted during rotations. Without exposure, how can a med student know what options there are? Furthermore, I also believe the way a course is taught does impact a med student's decision to pursue a particular specialty. If you're not interested in only looking at the heart, you won't be a cardiologist. If you suck at dissection in anatomy, you should not be a surgeon. Perhaps that's a gross oversimplication.

The curious thing about clinical human anatomy is that, on the first day, we were subjected to a 2-hour long lecture on the ethics of cadavers and respect for them. We were actually warned to not allow anatomy to distance ourselves from our future patients, but rather to bring us closer to them (I'm not exactly sure how this would work). It is interesting, however, that many mainstream media report how patients actually abhor doctors who view them with dispassionate interest - who view patients more as a "bag of symptoms" rather than as a holistic individual. We've been told, time and time again (and just within this last week), how patients don't care how much a doctor knows but rather how much a doctor cares. Call me idealistic (and I suppose I am, for being just a lowly M1), but I would like to believe there is a way to balance the "caring" side with the objective side of clinical medicine.

As for memorizing the brachial plexus, I don't have a choice. It will be on my exam (in quite a bit more detail than I'd like, I imagine) in a few weeks. Besides, I don't think anatomy's stupid. It's good to know where the major things are. I've heard that other med schools do less dissection work, as anatomy is a "dying art." That's rather unfortunate, in my opinion.

Finally, if you read this, thank you again for your comments. It would be interesting to read what you had to say about my previous posts, particularly the ones that relate to health and medicine. As it is, I understand you probably don't have time for that and so I truly do appreciate you taking the time to comment on my last post.

---Edit---
Hi again AD! :) Thanks for commenting further in this post. I won't copy your text, as people should just refer to the comments section of this post below.

I would like to ask you a few questions (if you don't mind answering, hopefully you read this): is it possible to do a fellowship in medical genetics after doing residency in pediatrics? Or is the only "route" to medical genetics through internal medicine? And what kind of physician are you?

I took an embryology course in undergrad and actually really enjoyed it. Even some people in the biology department lament at the "death" of embryology, as developmental biology seems to have overshadowed it. It's a little saddening.

I'm really glad you brought up that point about pharmacists. My friend who's finishing up pharmacy school is actually most interested in hospital pharmacy (I think that's what it's called), where they follow doctors and residents as a part of a team and advise them on which drugs the patient should take. I'm not sure if it's everywhere, but just there seems to be a culture shift in the way medicine is taught and practiced, there seems to be a cultural shift within pharmacy as well. So hopefully by the time I'm done with residency (and fellowship?) I will be able to defer to pharmacists.

I'm also glad you pointed out how it's okay to say "I don't know." I had been wondering/worrying about that aspect of medical culture. I've read (and heard) how mortally dangerous it can be for doctors to either admit fault or that they don't know, for malpractice reasons. Of course, as a fledgling M1 I don't know much in such matters, but I've never had the ego to not say "I don't know" when I truly didn't (in fact, I'm quite uncomfortable giving advice/info that I'm unsure about). My genetic counseling friend refers to that tendency as evidence for my "extensive" scientific background, lol.

Lastly, I have not read The House of God but I fully intend to over winter break. My brother read it in one of his freshman seminars and I've heard many good things about that book. So it's about time that I read it. A book I have read and enjoyed was The Spirit Catches You And You Fall Down.
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Why Medicine?

So I'm going to get right to the point. Randy asked a few days ago (and I'm paraphrasing): "Why do people (and you) choose to go to med school?" So out of everything out there, why medicine?

I'm actually surprised I had not explained or elaborated on this before. Maybe I have in some post and forgot about it (and if so, I'm not going to dig through my 260+ posts to find it). I'll first enumerate some of the reasons that people go into medicine before I speak for myself.

Warning: This is a rather long post.
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Money, power, prestige, fame, the title, wanting to do good, desire to serve the community, desire to heal/cure/save lives, a calling - these are the main reasons that I believe people choose to pursue medicine. I will first and foremost speak of my peers at my med school. Most of the people I've met in the last 2 weeks sincerely want to be good physicians and "do good." Everyone has his/her own opinions and leanings towards this specialty or that based on life experiences to date. We all entered med school knowing full well the "sacrifices" we would be required to make, to have the next decade (or even longer) of our lives "locked down." We all entered med school knowing full well the $160K+ debt we are incurring (not including interest). We all entered med school knowing full well we would be sacrificing sleep, food, and sometimes sanity. But we all chose to do it because that is where we see ourselves, that is where we feel our career niche lies.

But as a result I have sensed, however, a feeling of entitlement to satisfactory rewards when we're "done" and out of med school and residency. It is the feeling that, because we're sacrificing perhaps the second best years of our young lives (the first best years being the 3-5 years of undergrad), because we're incurring astronomical debts, because we're - almost literally and ironically - sacrificing our own health to learn how to heal others, we should be compensated. And it is for this reason that many of my peers dream of interesting specialties that they can flourish in and/or of specialties that have a more "cushy" lifestyle.

We know that fewer med students willingly choose to enter primary care and that primary care is approaching collapse in the US. Yet many of us still wish to avoid it if at all possible. Why? It is because we're wary of primary care - of the low reimbursements, of how you can spend 15-30 minutes with a patient and get paid less than an operation that takes 5-10 minutes, and of the sense of powerlessness in primary care (as you're always referring away patients to specialties). I don't know if I've said this before, but I heard on NPR about a month ago how many pediatricians back in my home state are leaving due to the high unemployment rate and the now heavy reliance on Medicare/Medicaid. It's scary to hear that pediatricians don't make enough to keep their practices open, that many who've practiced for years are now going bankrupt. Almost everyone I've talked to one-on-one - nurses, doctors, med students - warn us to avoid primary care like the plague because we will not be able to make enough money to pay for office rent, electricity, water, internet, heat, staff salaries, malpractice, loan repayments, etc.

And so, while many of us want to help the community and want to do the most good we can, we do not want to do it at our own expense. The culture of medicine is changing - med students today do not want to be on call all the time, med students today want to help others but also want to have a family and a life outside the hospital. I had linked to a blog article in my post here. As my friend, RZ-F (who's an M2 at Case Western), said: "I did not go into medicine to make a net income of $65K for a few years and have to pay the ridiculous loans. I did not go into medicine to not be able to truly help patients and having to refer them away. I did not go into medicine and 'sacrifice' a decade of my life for nothing." I found an interesting clip on NPR (here) that mirrors the sentiment med students have towards primary care; please listen to it as it really speaks the truth.
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Now, as for me. I had wanted to go into pediatrics for a very long time (sorry, I won't be doing prostate exams, lol). A good part of me still does. But I've heard strong admonitions from the doctor I shadowed (an internist/endocrinologist, I'll call him Dr. L) against going into pediatrics and psychiatry. And every med student I've talked to kind of backs away from me slightly when I express my interest in pediatrics (they actually look at me as if I'm slightly crazy, no joke). One guy said, "Man, you must have a very good soul to go into pediatrics. AND you must be very tolerant, especially of parents." Of any of the primary care fields, pediatrics is the one to be most avoided. So then, why pediatrics?

I feel pediatrics is where I can do "the most good." And I LOVE kids, I think they're the best. I tend to connect with kids very well and I think they should be given more credit. I believe that children require a strong health advocate and also that they're entitled to know what's going on with them. Children should, to a certain and varying degrees (depending on age and maturity and such), be aware and have a role in their own health care. Many times doctors tend to talk at or to the patient, and not with them. I feel my communication skills, that I've learned and refined a bit from teaching undergrads, allow me to explain a complex issue in a simple way without simplying the issue. It allows me to be more of a teacher with patients, rather than a patronizing lecturer. I think I can even handle the parents too (hopefully).

That said, I know I cannot survive without incredible luck by being "just" a pediatrician. There are two specialties/sub-specialties that I'm considering: endocrinology or medical genetics. I shy away from most specialties because I don't like to delve too deep into one or a couple things, my interests are a bit ADHD for that, and I know right now I want nothing to do with surgery (the less cutting the better). General pediatrics is great because it spans the whole gamut of issues for individuals from 0 to 21 years old. Endocrinology is great because rather than focusing on one organ, it focuses on dozens scattered throughout the body. Medical genetics is great because genetics is emerging as being ever more important in medicine, and genes affect almost everything (and it'd be nice to "ride this wave" as it were). With pediatric endocrinology, I'd likely focus on obesity and diabetes, a growing epidemic in the US. With pediatrics and medical genetics, my primary patients would still remain children, but I could also see adults with genetics-related concerns (though I'd likely focus on prenatal and pediatric genetics, if possible).

So have I now mirrored my peers above? Have I sought a well-compensating specialty after doing residency in primary care? Actually no, lol. Pediatric endocrinologists don't make that much more than general pediatricians, and medical genetics actually makes somewhat less than general pediatricians (FUCK!!). I guess, if my current interests hold, I'm doomed to being a poor ass doctor. I can live with that, as long as no one sues me or yells at me . . . I didn't go into medicine for the money, or the power, or the prestige. I went into medicine believing I could truly help people and make them feel better, and maybe even save a life now and then. But man, that $160K+ debt is looking daunting about now . . . T.T

It's going to be a tough life, but maybe less so if I manage to achieve my even more ambitious goal. More than being "just" a pediatric endocrinologist or a general pediatrician with a focus in medical genetics, I want to go into academic medicine. While I have little interest in pursuing research as a primary focus, I wish to go into academic medicine (almost solely) for the opportunity to teach students, whether they are undergrads, grad students, or med students. I truly do love to teach and prior to last year, I wouldn't even have known. If I'm lucky I might get tenure, lol.

Suffice to say, I don't know if all will go as planned. I don't know if I'll break down and change my mind (and pursue a "cushier" specialty), or where life will take me in the coming decades of my rising career. But hopefully I'll have the resolve, the will, and the luck to make it out and still be me, still maintain my idealism, have a family, and have a life outside the examination room. Here's hoping.

Oh, and Dr. L told me an amusing joke. "The internist knows everything but does nothing. The surgeon knows nothing but does everything. The pathologist knows everything and does everything, but it's too late. The patient's already dead." I guess it might only be interesting to those in medicine . . . If you're curious as to what it all means, ask me about it.

---TANGENT---
Oh, I just read up on a new blog called Daze Gone Bi by Dave83201. If you haven't had the chance to go over and read, please do so and you can let him know I referred you. ;-)
---END TANGENT---

Under the Shadow of Leaves

It is a good day.

I sit on a stone bench under the shadow of leaves, the sun poking through as if light were leaking through the green canopy. Looking out, the sky is clear blue except for the presence of a few wispy clouds. The day is bright and full of colors forgotten in the seasons prior.

I close my eyes and hear the sounds of toddlers and children laughing, of students talking, of many feet walking by. I wonder, how many hundreds of thousands of people have passed this point? What were they thinking as they passed by? The birds above sing their chorus in a language I cannot decipher. Far off a group of people are playing some instruments - a guitar and some drums. Though unrefined and unpolished, the sounds mix organically into carefree music.

A breeze blows by, carrying with it the scent of approaching summer. It is the smell of leaves, of living wood, of flowers, of the stone buildings - sentinels that resist the wear of time. It is the smell of life itself, and nourishes my lungs in a way I had taken for granted. I hold out my hands and arms into the breeze, as if to slow it down or capture it. Instead, the invisible force flows up over and down under my arms. It flows between my fingers, eddying slightly and briefly into an almost tangible ball in the palm of my hands. It feels as though I was almost able to grasp the breath of the world.

Something speaks to me, faint just beyond the detection of my senses. I see nothing, hear no words, smell no source, touch no object - but it is there. It surrounds me like an emotion but is not an emotion. Suddenly it feels as if things will be okay. And all those times I have tried to believe, to rationally seek answers to the mysteries, to understand that which cannot be tested, all this does not matter. It is there, it is here, and somehow I know things will be okay.

I open my eyes and walk away from my stone bench, away out from under the shadow of leaves. I am cloaked in the day and the moment and the world and this mystery. I will be okay.

It is a good day.
-----
A small prose passage. A memory - a snapshot capturing what I feel on the best of days. It is curious how I never expect it but always welcomed, replenishing my inner strength.

You may have noticed my new blog title banner thing. I'd like to give a HUGE shout out to J of Southern Inebriation for designing it for me at my request (he's an art major, can you tell?). I will explain the 5 panels of this banner from the left to the right:

The first panel is of Chinese opera masks and the Great Wall. It represents my background: being Chinese, culture and language has been a huge influence in my life (sometimes good, sometimes bad). The second panel is of a stethoscope on a book. It represents my future, my goals and aspirations: for a long time I have worked my ass off towards getting into medical school and (hopefully) I will come out poised to be an excellent doctor. The third panel you should all recognize as the smiley face banner I had previously. It represents outlet and others: it is this blog and all of you who read, and all of you I talk to. The fourth panel is of a flower I took while visiting a clinic in China. It represents life: I was a biology major in undergrad not primarily because it's the "easiest" path to medical school, but because it can give one an appreciation for life - for all its complexities, and mysteries, and frailty, and endurance. The last panel is of a ghostly mask of sorts. It represents conflict and struggle: all the uncertainty and frustration that being bi/gay brings and a kind of loneliness that comes with an inability to find "the one."

Finally, to conclude this post, I would like to give a shout out to the following 3 blogs that I've had the pleasure to read fully on. They may need no introduction as many of you already read them, but if not, do go over and say hi! And they are:

Enjoying the Journey
Hellogenation
Overrated Integrity

A Breath of Our Inspiration

I didn't have a Thanksgiving post (obviously). I don't know if anyone missed me in my week's absence, somehow I doubt it. First, I'd like to direct people to AJ's and Matt's blogs, to give them words of encouragement and love and all that in this time.

I came across the following poem again, and it was, as a line in there, "A breath of our inspiration." There are powerful words in that poem, words of inspiration and change. That we can all be an agent of change. That we are the shapers of our collective future. I know not everyone's fond of poetry, but it's a good read. Enjoy.

-----

Ode
by Arthur O'Shaughnessy (1844 - 1881)


We are the music makers,
And we are the dreamers of dreams,
Wandering by lone sea-breakers,
And sitting by desolate streams; --
World-losers and world-forsakers,
On whom the pale moon gleams:
Yet we are the movers and shakers
Of the world for ever, it seems.

With wonderful deathless ditties
We build up the world's great cities,
And out of a fabulous story
We fashion an empire's glory:
One man with a dream, at pleasure,
Shall go forth and conquer a crown;
And three with a new song's measure
Can trample a kingdom down.

We, in the ages lying,
In the buried past of the earth,
Built Nineveth with our sighing,
And Babel itself in our mirth;
And o'erthrew them with prophesying
To the old of the new world's worth;
For each age is a dream that is dying,
Or one that is coming to birth.

A breath of our inspiration
Is the life of each generation;
A wondrous thing of our dreaming
Unearthly, impossible seeming --
The soldier, the king, and the peasant
Are working together in one,
Till our dream shall become their present,
And their work in the world be done.

They had no vision amazing
Of the goodly house they are raising;
They had no divine foreshadowing
Of the land to which they are going:
But on one man's soul it hath broken,
A light that doth not depart;
And his look, or a word he hath spoken,
Wrought flame in another man's heart.

And therefore to-day is thrilling
With a past day's late fulfilling;
And the multitudes are enlisted
In the faith that their fathers resisted,
And, scorning the dream of to-morrow,
Are bringing to pass, as they may,
In the world, for its joy or its sorrow,
The dream that was scorned yesterday.

But we, with our dreaming and singing,
Ceaseless and sorrowless we!
The glory about us clinging
Of the glorious futures we see,
Our souls with high music ringing:
O men! It must ever be
That we dwell, in our dreaming and singing,
A little apart from ye.

For we are afar with the dawning
And the suns that are not yet high,
And out of the infinite morning
Intrepid you hear us cry --
How, spite of your human scorning,
Once more God's future draws nigh,
And already goes forth the warning
That ye of the past must die.

Great hail! We cry to the comers
From the dazzling unknown shore;
Bring us hither your sun and your summers;
And renew our world as of yore;
You shall teach us your song's new numbers,
And things we dreamed not before:
Yea, in spite of a dreamer who slumbers,
And a singer who sings no more.

Found at this link.
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---TANGENT---
Okay, so I seem to have this ever-growing list of blogs I intend on reading and then linking to my blog. I will work on that . . . once I'm done with my term paper and exams and have nothing to do over Winter Break (in about 3 weeks). I also need to go through all the blogs and sort them out over Winter Break (I have WAY too many links, and they just keep increasing). In the mean time, I'd like to link to these 3 blogs that I managed to catch up on:

Call The Shots
The Covert Homo
This is my life...

So go over and say "Hi," among other nice things. :D
---END TANGENT---

Election Wrap-up

I spent the evening watching the election last night, and consequently got no work done. Oh well. As people may (or may not) have noticed, I try to keep politics out of this blog because I don't much like politics. So just a few things:

1. I'm glad Obama won. I hope he'll be able to deliver the change he promises and the change that we so need as a country after 8 years of Bush. I have no doubt he'll be a competent and capable president, but I feel just a little bad as he's charged with cleaning up all that Bush messed up.

2. McCain is a great and respectable man. There was a time (at the very beginning of the campaign) that I might've considered voting for him. The closer it got to election time, the more that evaporated. Yet, he exhibited dignity and grace in his speech accepting his loss in the election.

3. California, we've been watching your Prop 8 here. Of all the states with that initiative on the ballot, we never expected it to turn out so close with "Yes on Prop 8" slightly ahead. Last I checked, not all the precincts were in, so there's still hope that "No on Prop 8" will win the day. I'm keeping my fingers crossed for you. If for no other reason to support "No on Prop 8," it's that if Prop 8 passes, it'd be a clear violation in my mind of the Separation of Church and State. And I hold that concept pretty sacred.

4. I am ecstatic to say that Prop 2 in my state passed (barely), which means "looser" restrictions on embryonic stem cell research. Prop 2 is actually a very specific and detailed proposition that has many limits on obtaining embryonic stem cells (see my past post here for more). So "looser" really means "at all" and with all the attendant restrictions at the state and federal levels.

Now, to go research for my term paper on pre-implantation genetic diagnosis (aka, embryo screening). And to study for my pathophysiology exam next Monday. I do love that class, lol.

Life is for the Living

---TANGENT---
I'm putting the tangent at the beginning this time because the post following this is quite long. So there appear to be an exponential increase in blogs of late, haha. I haven't gotten around to all of them (or even the older ones that I've had bookmarked for some time now). But I did get to the two following:

a story of a boy and the universe
I Gotta Story To Tell

So if you get a chance, go over and say hi. :D
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There is a proposal of great concern in my state right now. I know this issue isn't one in many other states, but mine has one of the strictest limitations. And that is Proposal 2, which if passed, would make embryonic stem cell research legal in my state.

Proposal 2 would allow embryos that would otherwise be discarded from fertility clinics - because they're either diseased, inviable, or were created in excess of fertility treatment - to be allowed to be donated to labs to conduct embryonic stem cell research on. Again, these embryos would have been discarded because they're either no longer useful or could never be useful in IVF; and now they can be used for embryonic stem cell research instead of being wasted.

I keep seeing in the student-run newspaper letters to the editor against embryonic stem cell research. And it infuriates me because it exposes the obvious misunderstanding and lack of knowledge on this subject. It's even likely that these opponents of embryonic stem cell research won't even look further into the issue, or that's at least how they sound. I will attempt to debunk several myths/misconceptions used by opponents.

Before I begin, let me very quickly elaborate what embryonic stem cells are. When the embryo is only a few days old, it becomes 2 kinds of cells - the trophoblast and the inner cell mass. These two cells form a hollow ball with the inner cell mass inside the trophoblast (the embryo at this state is also called a "blastocyst"). The inner cell mass has the ability to become any kind of tissue in the human body, whereas the trophoblast cells become all the kinds of non-body cells (i.e. the placenta, amniotic sac, etc). Adult stem cells are partially differentiated, meaning that they can only become a handful of different cells. For example, bone marrow is more or less blood stem cells, so it can become any kind of blood cell in the body. There are skin stem cells that just become skin. So on and so forth. Now to the issues.

The first is that embryonic stem cell research would take away funding from adult stem cell research, which has been proven effective in over 70 different treatments. This is egregiously wrong on many levels. First, embryonic stem cell research would not take away funding from adult stem cell research. Both kinds of stem cells are very important and need to be researched. It stands that adult stem cells just aren't as powerful, or potent, as embryonic stem cells. Also, all of those 70+ or so treatments using adult stem cells are not yet approved and can't be used by the public. They're still in the infancy of clinical testing, or stage 1 (maybe stage 2 if lucky). The most promising thus far is cord blood from the umbilical cord, where the adult stem cells there can be used to create any kind of blood cell in the body to replenish the body's ability to make blood cells after blood cancers like leukemia. But that's all they can do.

The second is why do we still want to use embryonic stem cells when there have been successes in "re-programming" adult stem cells to behave like embryonic stem cells? Well, it's certainly true that by fiddling around with 4 genes that researchers can "revert" adult stem cells back into embryonic stem cells. The problem here is that to do this the researchers have to use a virus to introduce the necessary genes. That's hard and will never pass clinical trials. The second problem is that these 4 genes also control cancer. So in a lot of samples, rather than becoming embryonic stem cells, these re-programmed cells become cancer. And there hasn't yet been a lot of success in bypassing that and making the "reversion" more efficient. So this is more costly and dangerous than just using embryonic stem cells in the first place, though it's an avenue of research that should (and will) continue to be pursued.

This last one is the one I personally hold the most frustration against. And it's the idea that to get embryonic stem cells that embryos are destroyed. Let's be clear on the word "destroyed." Destroyed, as I understand it in this context, means death or the cessation of life. So when embryos are discarded from fertility clinics, they are verily destroyed. Killed, what have you. Embryonic stem cells on the the other hand are very much alive, in fact, they're immortalized. A researcher takes the inner cell mass and grows them on a plate indefinitely, so they're technically still alive. Yes, the embryo as a functional unit is destroyed. But as far as the properties of living go, these cells are very much still alive.

An extension of this is that life is being destroyed when the embryo as a functional unit is destroyed. Let me reiterate, many of the embryos in fertility clinics can't survive anyway. Again, there is no way these embryos can ever develop into a person because they have a defect in their genomes. It's estimated that 2/3 of all pregnancies end in miscarriage and most of the time the woman doesn't even realize she's miscarried. Even the diseased or defective embryos are of use to science because with them we can understand the genetic background underlying development and genetic diseases. If we know that a particular embryo will develop a particular kind of genetic disease, then drugs can be tested on those cells rather than on animals or people.

I'm not going to trample on anyone's definition where "new individualistic life" begins, but know that most of the time, these embryos just won't survive anyway. And the extras will just be thrown away. Discarded. Destroyed. Dead. Why not put all of these - both the ones that can't survive on their own and the extras - and give them a purpose? If one truly believes that life begins at conception, then every single embryo in a fertility clinic - regardless if it can survive or not, if they're extra or not - should be implanted into a woman somewhere and given a "fair" chance at developing into a person. And this just won't happen. It can't.

I watched a documentary a couple days ago called "Life is for the Living." And you see in there all these people with these horrible dieases and accidents such as Parkinson's, type I diabetes, spinal cord injuries, etc. And right now there are no cures for these. Embryonic stem cells do offer real hope and real potential. If research happens, there could be a cure for these problems one day. I could feel my tears well up several times throughout the film and it's hard to believe that people would deny these people, with all the suffering they've had to put up with and people that are fully realized as human beings, a hope or a chance at a treatment or cure.

So here's the issue: there are about 100 million Americans suffering from diseases and disabilities every day and embryonic stem cell research offers the hope for treatment and cures. That's about a third of the US population we're talking about here. And the question is this: are you willing to let these people suffer because you don't want to "take life" by allowing embryonic stem cell research using embryos that will never have a chance of developing into a person anyway? Would you rather save the thousands of embryos in a clinic to be discarded over the millions suffering today, every day?

If after this and you're still against embryonic stem cell research, fine. That's your decision. No one can stop you from opposing it. But please don't deny the millions of people the hope they need. If you don't approve of embryonic stem cell research then don't use any therapeutic treatments or cures that arise from the research. And heaven forbid, if in the future you should break your spine, or get Parkinson's, or get Alzheimer's, just know that you said "no" and that you are happy and proud to refuse any treatment and/or cures that arose from embryonic stem cell research that could improve or even save your life.

A Theological Discussion

In one of my courses today, "Issues in Public Health Genetics," we had a guest lecturer (SBK-F) discuss the theological issues concerning public health genetics, or what are theological issues in general. Apparently, there's such a thing as a Doctorate in Ministry in Spirituality. Her discussion today was so inspirational that I thought to discuss it here.

First a few disclaimers. I apologize for writing her words in any way less precise than she had described them herself to us. I'm going off the imperfection of human memory (and her PowerPoint slides), so pardon my distilled and potentially diluted words. This following will be long, so be patient if you're going to read it all. Also, no attacking me!! Lastly, keep an open mind.
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SBK-F puts forth an idea called soulful reasoning. It is a means through which we take a step back and look at the whole human being. It is a holistic approach that posits that we are all more than the sum of our parts, that we can sense something beyond what is tangible to our five senses. Soulful reasoning is also a means to connect spirituality and science as partners.

What is meant by spirituality? And what is meant by religion? The two are not synonymous though they are intimately linked such that it's difficult to separate them. Spirituality is the "beyond," the "more than" that we sense beyond our five senses. Different cultures give it different names. Religion is the means through which different groups of people understand and connect to spirituality, ultimately how we manifest spirituality.

SBK-F present this quote (from who I forget) that goes something like this: "There is a realm for which there are no words. There is then a realm for which there are no words yet we grasp for words. And then there's the realm for which there are no words and yet we settle on words because we need words." Spirituality is like that first realm, a place for which we have no words. Religion is like the last two realms, a place where though we may not have the words, we give it words because we need them.

What is faith and what is ideology? Both are meaning systems and must be developmental, dynamic, and always growing and essentially alive. Neither can become static or else they hazard becoming too rigid and ultimately obsolete. Faith deals with the final or ultimate questions, seeking understanding of the unknowable. Ideology is the practical means through which faith may be executed. Religions all contain both the elements of faith and ideology. The fundamental danger of both faith and ideology is to avoid dualism. Dualistic thought is where things are clearly divided into discrete categories. For example, good and bad, right and wrong. Both faith and ideology need shades of gray in which to operate. There cannot be only good or bad, only right or wrong.

Values are a set of principles, standards, or qualities considered worthwhile or desireable. They may be things, ideas or people that are important to us and give our lives meaning. They help us make decisions and choose paths in life, shaping our behavior and defining who we are. The stronger the value is to us, the less willing we are to change or compromise them - this in itself is dangerous. There are many different "kinds" of values ranging from personal to religious to institutional to societal to cultural to work. In many cases values may overlap in several categories. Core values are the set of values that we stand for, are the most important, and that we encourage.

Moral values (or simply morals) are the standards of good and bad that govern an individual's behavior and choices. An individual's morals may be derived from society, government, religion, or from oneself. A "set of morals" as a whole are not derived from a single source (such as society or religion) though "individual morals" may be derived from a particular source. Morals are a source of great power but also of great danger. Morals present the pitfall of becoming dualistic, of saying with "certainty" what is right or wrong, what is good or bad. We need to always be aware that there are gray spots that morals operate in.

When moral values are derived from society and government they will change as laws and the social mores change. An example given was impact of law changes on the moral values between marriage and "living together." Several decades ago it would've been appalling for people to simply "live together" without getting married. Today there are options and people are freer to choose. Morals derived from oneself is shaped by our experiences from childhood to adulthood and help us determine what's acceptable and what's forbidden, kind or cruel, generous or selfish. Going against these morals tends to elicit guilt. Lastly, most religions have built-in lists of morals that individuals of that religion follow. For example, the Ten Commandments, the Golden Rule, the Five Pillars of Islam, the Five Precepts of Buddhism, the Ten Dharma Embodiments of Hinduism.

Spiritual values and religious values are often used interchangeably though they may be used to distinguish between human values and doctrinal beliefs that become expressed as values. The two are not necessarily the same but often share a lot of overlap.

The following is what leads me to believe in the "more than" which has been called Enlightenment, the Oneness of the Tao, the Divine, Heaven, etc.

There are five human values that are found across ALL spiritual traditions: truth, righteousness, love, peace, and non-violence. Furthermore, there are very similar religious values that seem to apply to a universal ethic of human respect and dignity. (The following are copied from her PowerPoint slides, so I don't know for sure if they're quoted exactly from the sources.)

Buddhism: Hurt not others in ways that you yourself would find hurtful (Udana-Varga 5:18).

Confucianism: Surely it is the maxim of loving-kindness: Do not do unto others what you would have them do unto you (Analects 15:23).

Taoism: Regard your neighbor's gain as your own gain and your neighbor's loss as your own loss (T'al Shang Kan Yin Pien).

Judaism: What is hateful to you, do not do to your fellow human. That is the entire law; all the rest is commentary (Talmud, Shabbat 31a).

Christianity: In everything do to others as you would have them do to you; for this is the law and the prophets (Matthew 7:12).

Islam: No one of you is a believer until he desires for his brother that which he desires for himself (Qu'ran, Sunnah).
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So what are some "take away messages" from the discourse presented by SBK-F through me? What I got out of it is that it's dangerous to hold onto a value or moral in a very tight grip. If one holds on to it too tightly, they lose sight of its source, they lose sight that there may be alternatives that are just as good. We all operate in the gray area between two extremes and that if we were to ever eliminate this gray area, conflict results. Because if one person believes he/she is right "beyond any doubt," does that mean necessarily that everyone else is wrong? Also, morals (and by extension morality) does not solely stem from religion. It does, in part, but not entirely. Like many things in life, morals are complicated and are derived and synthesized from many influences, whether we recognize it or not.

Also the most powerful message is that, regardless of religion or non-religion, everyone seems to share the same basic spiritual and human values. SBK-F had us do an exercise in class where she dictated to us the public health values and assigned each group of three a set of personal values and a set of institutional/work values. And we had to come up with 2-3 spiritual values to reconcile or appeal to those disparate values. The most interesting thing is that everyone ended up choosing very similar spiritual values (sometimes with different terms, like charity and compassion, but ultimately similar) but used them in different ways to deal with the very different value systems laid before us.

So that which unites us, all of us - whether or not we're religious, whether or not we believe we're spiritual, whether or not we share the same values and/or morals - is somehow something fundamental to everyone. It is something "more than," something greater and beyond us, something we can't sense with our five senses and yet know is there, whether we recognize it or not.