Skepticism Against Non-Neutrality

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

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

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

Washington Post: Americans push back against CDC recommendation on circumcision

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

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

Heck, this topic has been covered (albeit tongue-in-cheek) by Queerty!  For example:

• If Circumcision Haves Risk of Spreading HIV, Should All Baby Boys Get Cut?
• So Circumcision Won't Help American Men Stop Spreading HIV?
• Even If Circumcision Helps Prevent HIV Transmission, Good Luck Finding American Guys It Could Benefit
• For Gay Men, Cutting Off Your Foreskin Not As Good As Condoms To Keep The HIV At Bay
• What's All This About The Government Wanting American Teenagers To Get Circumcised?

And to reference my previous post, the media can write about a single topic in two ways.  Queerty is clearly on the opposite side of the articles posted in my previous post.

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

Media, Culture, and Half-Truths

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

Reuters "Male circumcision benefits outweigh risks, US CDC says"

The Verge "Benefits of circumcision outweigh the risks, US CDC says"

Yahoo "CDC: Circumcision benefits outweigh risks"

LA Times "Circumcision cited as defense against HIV in proposed CDC guidelines"

NY Times "Circumcision Guidelines Target Teenagers"

TIME "Feds Say Circumcision Best for Boys"

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

Media

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

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

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

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

Culture

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

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

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

Half-Truths

Now on to the merits of what's been discussed/argued for in the articles.  The best quote I could find comes from the LA Times article: 

"Dr. Thomas Newman, a professor of epidemiology and biostatistics at UC San Francisco, says he believes that the medical benefits of circumcision outweigh the risks but that both are small."

This is the closest thing to the truth out there.  Let's look at the arguments on the table:

Pro:

• Circumcision reduces HIV risk by 50-60%.  Well that effect is quite small on an individual level, as illustrated above.  Plus, condoms reduces HIV risk by 90-97% when used correctly.  That "additional" 50-60% is rather meaningless.  Furthermore, circumcision offers zero benefit for those most at risk of getting HIV in the US (men who have sex with men, IV drug users).
• Circumcision reduces HPV and other STI's.  Maybe true.  But we now have a vaccine for HPV that's 98-100% effective.  And again, condoms.
• Circumcision reduces UTI's in boys during the first year of life.  This is actually true, however, the risk of getting a UTI is rather small to begin with.  In a healthy uncircumcised baby boy, the risk of getting a UTI is 1 in 100.  In a healthy circumcised baby boy, the risk of getting a UTI is 1 in 1000.  In girls older than 1 year of age, the risk of getting a UTI is like 5-7 in 100.  And how do we treat UTI's?  With antibiotics.  That said, there is a role for circumcision in a baby boy who gets recurrent UTI's (and usually there is some other anatomic problem as well).

Cons:

• Risk of complications.  I love how they kind of lumped all complications together, and then say that it's about 1% if the procedure is done before 1 year of age, 9% if done between 1-9 years of age, and 5% if older than that.  I don't know about you, but a 5-9% complications rate is pretty high.  And what are these complications?
• Infection and inflammation are a common one.  As with any invasive procedure, there is always a risk of infection.  And think for a moment, this baby's penis is healing while he's in diapers, exposed to urine and poop.  That can't be pleasant.
• Bleeding is another common one.  Well, this could be life-threatening if a baby has a bleeding disorder (like hemophilia).  I'm sure the majority of the time no one does blood tests before the procedure to confirm that a baby does not have a bleeding disorder, and often times a family history can only get you so far.
• Other risks not mentioned?  Adhesions, meatal stenosis, and accidental amputation are ones that probably should be mentioned.
• Adhesions: baby's bodies heal very well.  Sometimes parts of where the foreskin is removed will reattach itself to the glans (penis head).  This can cause not only cosmetic issues, but also functional issues.  Sometimes those adhesions are so tight that erections can be uncomfortable.
• Meatal stenosis: when the opening of the urethra (pee hole) is too small to allow urine to pass.  This problem exclusively happens in circumcised babies and requires surgical correction.  The end of the penis is not meant to interact with the outside world before puberty, and so exposure causes inflammation, which causes swelling, which causes a small hole to get smaller.
• Accidental amputations: yes, very rare, but very very tragic when it happens.  A handful of cases happen each year and it's impossible to remove this risk entirely.  It may be a 1 in a million risk, but if that 1 in a million is you or your baby, and it wasn't medically necessary, you would probably be pissed off.
• Also none of the articles mention studies that support the foreskin being a very innervated area of the body.  Whether those nerves play a role in sexual sensitivity and enjoyment is a topic of debate in and of itself, but logically it would make sense that more nerves = more sensation.

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

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

In Other News . . .

So what's up with me otherwise?  A quick summary:

I passed USMLE Step 3!  Woohoo!!  Really, the odds of me passing were vanishingly slim but you always worry on test day.  I was amused that I did worse as the patients in the questions got older.  Definitely affirms my training in pediatrics, lol.  Also my highest sections were Behavioral/Emotional, Musculoskeletal, and Immune/Infectious Diseases.  Fascinating, because it leads me to . . .

I'm like 95% sure I'm going to pursue fellowship in pediatric rheumatology.  It's definitely one of the least "sexy" subspecialties because: 1.) there aren't many procedures, 2.) it pays less, and 3.) it's not well understood.  But I find it fascinating.  It commonly affects joints (as you'd expect), but it can really affect almost any organ in the body.  And I seem to be one of the few peds residents who kinda likes (or at least doesn't mind) teen patients.  It's also a rather "rare" subspecialty, there only being 26 fellowship programs in the country (for about 60ish spots).  There's an estimate of about 1/2 the number of peds rheumatologists in the country as there needs to be.  As one senior resident described to me, doing this fellowship is basically a golden ticket to practice anywhere in the country that I so desire.  Yeah, I'll make less money.  But to echo one of the peds rheumatologists that I worked with, "I didn't come from money.  So this pay is pretty good to me."

It's astounding how stress and sub-optimal nutrition leads to weight gain!  I seriously gained like 15 lbs in residency so far.  No bueno!  I just started working out and slowly ramping things up.  I'm woefully out of shape, but that's what I get for being on inpatient rotations for 5-6 months in a row, working on average 6 days/week, and up to 80 hrs/week.  Where in there is there time for working out, much less healthy eating?!  For the first time in many months, I have the time and there wherewithal to realign my health to where it should be.  I've been a poor example for my patients.

Today I was eating lunch outside with one of my co-interns.  And she remarked how nice it felt to have the wind blow on her face, how normal it felt, and how sad that she was thinking that in the moment.  But it IS sad.  This residency thing is not something I'd wish on someone else.  Fuck that, if I could re-do things, I wouldn't re-do this.  But I've already come this far and I'm going to see it to the end.  Because at the end of it all, I have a chance to regain normalcy.

Recently got into a new show, Looking.  It centers around 3 gay friends in SF.  It's entertaining.  About halfway through like the third episode, I realize that one of the main characters, Patrick Murray (played by Jonathan Groff), is basically me in a lot of ways.  He wants to have a good sustainable relationship, but sucks at it.  He's conservative in his actions and tends to thinks before he acts (sometimes too much).  Anyway, a good show to check out.  :-)

First Time

The First Time by ~ChadtheFab on deviantART

Welp, no longer a virgin anymore I suppose.  It was meh.  But perhaps I should backtrack.

Yesterday, a (gay) friend visited me who I haven't seen in almost a year.  I've known him for probably 4-5 years or so.  He's in the process of moving out of his town to literally halfway across the globe, so I insisted that he visit me before he left the country.  We had also flirted/bantered online back and forth about all this (sex), so none of it is any surprise.

So anyway, long story short, we had brunch, we hung out a bit, we went back to my apartment where I eventually coaxed him.  We wanked each other a bit before I ask if he was up for "something more."  I handed him a condom and lube and asked what he wanted to do - he would top, and I would bottom.

He asked, "Don't you want your first time to be special?"

To which I replied, "Meh, I'm over special.  Plus this is special in its own way."  I've been holding off and waiting for so long, I don't really care anymore.  I'd much rather it be him than some one night stand whose sexual history I know nothing about and will never see/talk to again.

So he put on the condom and lubed up . . . it wasn't enough lube.  It hurt when he tried and I told him to stop.  He applied some more lube and then slowly entered.  It was alright.  He's about 7 inches and somewhat thick.  He slowly ramped the speed of his pounding - I didn't like that too much.  He never hit the good spots (aka, the prostate) for very long back he was going faster; it felt much better when he slowed down.  Eventually I actually kinda got bored and told him to stop, and we'd just wank each other to finish.

He then did this thing to me that he discovered accidentally a while back with some other (uncut) guys.  He just rubbed the bare head with his lubed hand and I was soooo sensitive - he had me squirming and twitching.  It felt tortuously good, but it wasn't the kind of good that gets me to orgasm.  At one point I'm pretty sure I shot out pre-cum, as I felt a spray of something up to my chest and shoulder; it definitely wasn't cum.

After he finished me off, I returned the favor.  I basically tried the same thing he did, but he wasn't anywhere as sensitive (he's cut).  However, when he came and squirted all over he chest - if he hadn't sat up slightly he would've probably shot over his head - I continued to rub his penis.  He suddenly got that post-orgasm sensitivity and I thought I'd repay him for basically doing what he did to me, lol.  He actually grabbed my hand to stop me - too bad he grabbed the wrong hand, muahaha.

So there you have it, my first time.  It was meh.  I suppose it's something to get used to, an "acquired taste" if you will?  Hmm . . . I imagine first-time sex with a woman may be more enjoyable, haha.

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My time with the last guy (post here) was way more enjoyable.  I think it was because of all the kissing and cuddling, it just felt way more affectionate.  Oh well, experiences.

To Hold and Be Held

Held so tightly by ~TopScoff on deviantART

I had been debating whether to post this or not, but I've decided that I want to remember the event as vividly as I can.  The following will get graphic, so if your sensibilities are easily offended, please skip this post.  I assure you, I will blog again soon.

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I met him online months ago, in a forum not unlike this one.  We messaged for a while before we added each other's IM.  I had half-jokingly agreed that if I got an interview in his area, he must visit me and I'd take him on a date.  Sometimes the stars do align, if only briefly.

Several weeks ago I went to an interview near him.  When I arrived at the train station, he was sitting there waiting for me in a black hoodie and jeans.  He was thinner and slightly shorter than me with dark brown hair, mesmerizing grey eyes, and a short goatee.  We first stopped by my hotel to drop my things off then went to a nearby Thai restaurant for lunch - his first time having Thai food.  Afterwards we went to a local natural history museum; I totally geeked out and I think he was amused by it all, haha.  It was a tiny museum and so we decided to stop for coffee on our way back to my hotel.  We chatted for a while over our coffee - him a mocha, me a chai latte.

There were still several hours before my pre-interview evening event, so we headed back to my hotel to see if there was any good movies on.  As he flipped through the channels, I positioned myself behind him to give him a back massage.  He had been so stressed lately and there were so many knots in his back - there were knots in places I didn't know a muscle could knot!  I began on his shoulders and kneading his upper back, working the knots out.  As I moved down, I found knots between his ribs and in his lower back.  At this point he laid on his stomach so I could get better access to his lower back.  I got a bit daring and went further, massaging his butt and upper thighs - wouldn't you have known, he had knots there too (somehow)!

I gave him a thorough massage for a good 30 minutes or more before he sat up.  He leaned back into me until we were both lying on our backs on the bed.  He turned towards me and wrapped his arms and legs around me like a koala to a tree, and laid his head in the crook of my neck.  I rested my head on his, smelling his hair.  To hold and be held like this, to cuddle, was such indescribable pleasure and relaxation.  As he cuddled I stroked his back and arms with my arm that was wrapped around him.  This guy really loved cuddling.  It's on par with a little kid/toddler in the amount and quality of physical affection, and it was awesome to hold and be held like that.

With my other arm, I stroked his chest, his stomach - first over his shirt then under.  Then I moved my hands down to his hip and around under his boxer-briefs to grab his fuzzy butt a few times.  He didn't object.  To test the limits of this, I moved my hands around to the front until I felt the head of his cock, already hard and completely wet with precum.  I massaged it a bit with my fingertips until he rotated himself till he was on top of me.  He undid his belt and unzipped his jeans, the tip of his cock peeking above his underwear.

He leaned in for a kiss.  It was awkward at first on my end, as it has been a really long time since I had kissed anyone.  As we kissed I had my hands on his cock, giving it a few strokes.  He then took off his shirt, pants, and underwear, revealing his entire cock for the first time.  It was one of the most beautiful uncut cocks I had ever seen - he was so hard that his foreskin had pulled back entirely.  He claimed it was about 6.5" but it looked closer to 7" and was quite thick.  He leaned in to kiss again before reaching into my pants to find my cock hard and wet with precum (I don't usually precum much, unless I'm very aroused - which I was).  He undid my belt, pulled off my pants, gave my cock a few strokes, pulled back my foreskin and put my cock in his mouth.

He knew what he was doing, sucking and licking my foreskin in such an oh-so-exciting way.  He stroked me a bit before I had him lie back to return the favor.  I gave his cock a good squeeze and saw a large drop of precum bead at the tip.  I pulled his foreskin over and licked the tip in circles before pulling it back and tried to suck as much of his cock as I could.  I put my tongue between his foreskin and the head and licked in circles, causing him to moan a little.

At some point he was above me and we tried to 69 . . . it was hilariously awkward because we couldn't quite coordinate ourselves.  We mostly ended up sucking and playing with each other's balls and asses for a bit.  He had me stop a couple times because he was close to cumming, so I paused while he kept going on me.  I would've given myself completely over to him had he a condom on him.

Maybe an hour later I was close to cumming.  It's weird being on the edge of cumming but not quite being able to because someone else is in control and they switch it up between oral and different strokes just as you're about to go over the edge.  It had been a week since I had gotten off (not much time what with the constant traveling, dining, and interviewing) and I was soooo sensitive.  When I started to cum, it came out like a flood - it gushed with each spasm but in between it felt like cum was still pouring out.  One of the best orgasms I've had.

He had laid himself across me in such a way that my cum splattered his chest.  It was my turn to return the favor.  Soon he was moaning and riding the same edge that I had just been - almost there but not quite.  Finally I got him over and his cum sprayed all over.  I teased his cock head a bit - knowing it'd get super sensitive post-orgasm - until he told me to stop.  We cuddled for a little bit in the afterglow before quickly deciding that we should shower and clean up, haha.

He decided to spend the night with me after my dinner with the residents rather than drive back home.  We cuddled in bed for a while as we chatted and got sleepy.  We crawled under the sheets and he wrapped himself around me.  It felt nice, but . . . I failed to realize how warm another human body could be.  So I kind of overheated haha, and the AC/heater unit thing was making such a racket all night that I barely got any good sleep.  That said, I tried to cuddle every chance I could get without overheating (it's surprisingly awkward to sleep next to someone if you don't position yourself just so).

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

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.

Imagine . . .

. . . that you've been in love with someone for 2 years. Recently you are engaged to him; you couldn't be happier, life couldn't be more perfect.

Then out of the blue, he suddenly gets intense chest pain and belly pain. You take him to a nearby hospital. The medicine doctors spend 2 days trying to figure out what's wrong, meanwhile he gets worse and worse. Then they finally discover that he has an aortic dissection, and the worst possible kind at that! His aorta, the main artery that brings blood to the body, has split open from where it leaves the heart all the way down to his groin.

Your fiance is immediately transferred to a larger hospital in town, because leaving him where he is means certain death. The cardiothoracic surgeons manage to (miraculous) fix the aortic dissection in a grueling marathon of a surgery. Afterwards, the doctors notice that his legs start to hurt, swell, and turn dark. Immediately the vascular surgeons open up his legs to relieve the pressure and restore blood flow to his legs, hoping that they made it in time. Unfortunately, it was too late.

His legs are dying. They are causing him more and more pain each day, so much so in fact that it causes him to become delirious - he does not know where he is, he does not know what year it is, he does not know what's going on. He can no longer make medical decisions for himself. They turn to you, as his power of attorney, to ask if you would give them permission to cut off his feet. What do you do? What can you say? Cut off his feet in order to save his life (and his sanity)?

You agree. Days later, they come back and tell you that things are worse than they appear. More of his legs have died than they initially thought. They have to cut more off. They ask you to give permission to cut off his legs above the knees. What kind of decision is this? Your fiance will never walk again. But you agree to save his life.

And for the next several weeks, you get phone calls and every time you visit your fiance in the hospital, the surgeons find you and ask for permission over and over again to cut more of his legs off, because more has died and they can't predict or control it. What can you say? This is the person you love. This is the person you were going to marry! He no longer looks anything like his former self. But you love him . . . and you want him to live . . .
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This is the kind of story that I'm seeing more and more of on rotations. Being part of the care team detaches me emotionally from the situation. All we can focus on is doing what's best for the patient to help him live and move on with his life. But in the process, patients sometimes lose so much of themselves (literally) and family members have to make hard choices.

If you were the one making the decisions above for a loved one, how would you react? What would you do? Would you be strong enough to endure it?

A Helping Hand

a helping hand by *poivre on deviantART

A couple days ago in the resident's lounge, one of the physicians came in to round with his team (of residents and med students). Because the lounge is rather small, I overheard most of what they said.

They discussed this one patient in his 30s who didn't finish high school, has uncontrolled diabetes, has peripheral neuropathy (numbness & tingling in fingers and toes) as a result, has chronic pain, and is taking narcotic pain meds in order to bear it all. According to the med student and intern taking care of him while in the hospital, they report that he is unpleasant/uncooperative to work with, appears to be "throwing away his life," and just want his pain meds. The physician took this as a moment to ask, "Why?"

This segued into a discussion from the physician about here is a guy who's slipped through the cracks of health care. He takes narcotics for the pain, but narcotics likely make him sleepy and also feel not great, throwing him into an endless loop. His PCP (primary care physician) likely tried to truly help him once, but since he's uneducated and doesn't know how to manage his diabetes, thus his health deteriorated. In his frustration, his PCP likely labeled the patient as "non-compliant," which is technically true - but again, why? It became easier for the PCP to just refill his narcotics and send him on his way. His PCP is also an older physician who's likely jaded from seeing so many of his own patients fall despite his care.

Here, said the physician, was an opportunity for us - med student or intern - to turn the guy's life around. Here, in the hospital, where we have "control" we can say to him, "You need to get your act together and turn your life around." Here we can extend a helping hand and spend the time to give him the education necessary to manage his diabetes. He's a young guy and has a shot of doing well years down the line, why should we also abandon him just because he has a label of "non-compliance?"

I have friends who call their patients "idiots" for smoking and having a BMI of well over 40, and then gets admitted for pneumonia. Or for being alcoholics and developing acute pancreatitis as a result. Sometimes I look at one of my friends, who's overweight and gets winded after going up 2 flights of stairs (how sad . . .), and say "Dude, you get winded after 2 flights of stairs. When was the last time you exercised?" To which his response is, "I've been busy and I just don't feel like it." How dare he call his patients idiots for ballooning up to a BMI of 40+ (FYI, that's more than morbidly obese), for telling them to exercise and eat healthy, when he doesn't do the same and could be in their shoes 10-20 years down the line.

Anyway, righteous indignant rant over. We all, medical and non-medical alike, have an opportunity to turn someone's life around. We all fail from time to time, but that doesn't mean we no longer deserve help. Even so, I'm beginning to feel myself become jaded with adult medicine after just 2 months . . .

Thoughts?

So I read from time to time, as I'm wont to do. Today I came across this article:

No surprise for bisexual men: report indicates they exist

Lol, the title amused me. Of course bisexual men (and women) exist! The only way the title could've been better is if it had the words "Well, duh" somewhere in it. Some may be offended that it took a study like this to "prove" or "validate" our existence, but I'm rather amused. The study does have some limits, as all studies do. It basically assess those who're "perfectly" bisexual rather than people who self-identify as bisexual but may have a skewed attraction towards either men or women.

Thoughts?

Circumcise or don't? Quandary for parents
Fairly balanced article for something that inherently has a lot of bias. A fellow med student friend (at another med school) and I briefly discussed the article/topic. He's of a neutral opinion and would follow whatever medical recommendation would be at the time of his future son's birth (assuming he'll have a son). My opinion is basically the same as any other surgical procedure - if it isn't medically necessary right now or in the near future, then don't do it. 99% of the time, circumcision is not medically warranted (that is, there's something so wrong with the foreskin that circumcision is the only option). I then asked him if, in the future, the medical recommendation is as "neutral" as it is now, then what'd he do? He said that he tends towards conservative treatment, and hence would likely leave his son uncircumcised unless there were some very clear benefits that outweigh the risks (there aren't, as of current medical literature).

Thoughts?

Why medicine actively and legally stifles innovation
This was a particularly interesting article. The author certainly utilized a unique health care delivery model. Definitely worth a read. I find the idea of such innovation to kind of operate outside "the system" refreshing. It's a funny thing - they tell us (the med students) to think about every possible diagnosis in the differential for a patient's disease. Then the physicians proceed to systematically dismantle almost every suggestion we come up with except the most likely/obvious ones. I can't say they're wrong in doing so because if you keep asking a med student for something "outside the box," you're going to eventually hear ridiculously rare diseases that very few people ever get and very few physicians ever see. I don't question their knowledge and clinical judgment over mine, because it's obvious that they know far more than I do (almost more than I can possibly imagine myself ever knowing!). What I do question is the system at large that seems to repeatedly fail patients and ends up producing jaded physicians. There must be some way to rectify the system and this article was one step in that direction.

Thoughts?

Less Person, More Intervention

A couple days ago I was at an advisor's apartment to welcome students of the incoming M1 class. His wife, who has acute myeloid leukemia, was also present. By any statistic you can quote she has beaten the odds more than once. She's a tough one and still fighting on.

Almost 3 years ago when she first greeted me and others as freshly minted M1s, she was lively, warm, and motherly. Now, bald and weak from chemo, tanned as if her skin had been baking under a desert sun, and also on dialysis, she appeared so frail and mortal. I've seen this before - the frailties of the body, broken by disease and worn from treatment and intervention. But also peering through are the embers of a once-strong soul. I could tell through her heavy-lidded eyes that she wanted to be healthy enough to interact and engage with all of us, instead of lying on the living room couch. I could tell that behind her wearied smiles that she's fighting off her own suffering.

I read a blog article the other day by a doctor who experienced what it was like to be a patient. What he wrote seems to mirror some of the patient's I've seen. Being a patient in the hospital must be one of the most frustrating things in the world. You rarely fully know what's going on with you, nurses are poking you every 15 minutes to 4 hours, and doctors order things to be done on/to you as you lay helplessly. We just need to remind ourselves that, at the end of the day, we can go home. Our patients often can't.

It's easy to correct an electrolyte imbalance. It's easy chase a blood culture. It's easy to track labs. But it gets harder and harder to see patients as people and not a "bag of symptoms." You look at someone and you don't see a mother, a sister, a father, a brother. You look at someone and you don't see a baker, a chef, a nurse's assistant, a student. No, instead you see an alcoholic, a morbidly obese individual, a body part, an organ, a pulmonary embolism, a cancer. All of which is true, one can't objectively deny any of it.

But in the ICU (intensive care unit), I've seen people become less and less person and more and more medical intervention until all that's left is a body on a ventilator with an NG tube, a Foley catheter, an arterial line, a central line, and a telemetry attached. In that state the soul has probably fled and all that's left is a shell of a person kept alive, not for the patient's sake, but for someone else's (whether it's the family or the medical personnel).

A woman was brought in to the ICU today. Full code, meaning CPR and the whole deal. She should have been left to die in peace. As my senior resident said, "This is a special place of Hell that people are forced to suffer through when someone calls the code."

That said . . . people occasionally do get well enough to regain their humanity and go home.

Pandora's Hope

I've witnessed Pandora's Hope with my own eyes,
staring at its immortal form behind its mortal guise.
A blessing, a curse; making us toil long after the day is done,
pushing us harder through a battle that can't be won.
I can only guess at its motives and its reason
since its release from its God-wrought prison.

I have seen it visit you on the edge of death
as you lay gasping with each labored breath.
With your eyes tightly shut in silent pain,
Pandora's Hope burrows deep into your vein,
snaking its way from your arm to your heart
and leaving its eternal mark within your chart.

Defeated, futilely struggling, there you lay.
Can you even hear us and what we say?
Our words of strength reach not your ears,
in your unconscious darkness of pain and fears.
Lifeless are your feeble and atrophied limbs,
your vessel subject to Hope's every whim.

It's not your pain - your suffering - that Hope allays,
but rather our fears and insecurities that It keeps at bay.
And before we realized, before we even knew,
Hope, and Artifice, have crept their way into you.
Hollowed out, Pandora's Hope has made you its shell,
And all for us It traps you - here you dwell.

Patients as Diseases

Yesterday I had a sudden strange epiphany: we tend to treat patients as diseases. The people who've come into the hospitals have "become" their diseases. We're more likely to say something like, "my diabetic patient" as opposed to "my patient with diabetes." Subtle difference perhaps, but a difference nonetheless.

It just hit me. Outside of their diseases - there sole reason for coming into the hospital - I knew next to nothing about my patients. I didn't know that my HIV patient was once a baker and a tanner (it said so in his chart). I didn't know that my DVT patient lives with his son and grandchildren (he randomly told me one day). I didn't know my patients as people, only as pathologies. It suddenly didn't sit particularly well with me.

On the one hand, by focusing on their pathologies, I can do my job more efficiently and figure out what's wrong and how to (hopefully) fix it. But on the other hand, there's so much more to the patient than their diseases and there's an element of humanity that's somewhat missing. I mentioned this to one of my friends who's on the same rotation track as me, and he says, "Welcome to the real world."

Yesterday my attending and I were rounding one of our patients with diabetes. She'll likely need her toe amputated because it's basically dead and rotting. And she started crying. My attending says to her (paraphrased), "You have become your disease. You have to get your life back and control this, don't let your disease control you. Knowing what it is is half the battle. The hard part is what you do, and I know it's not easy. But you must not let your disease control you."

We're all so wrapped up in the medicine, in the problems, that we fail to see the bigger picture of the world we live in. I don't know if knowing my patients as people would contribute to better patient care. Maybe it would help me understand how and why one of my patients became so obese that she could no longer sit up, roll on her side, or walk. And maybe, just maybe, it'd give me that small window of opportunity to help my patient manage her health once she leaves so that I never see her again.

A Good Day

It's been a good day.

1. I finally had an adult patient with a "fix-able" disease. He had pseudogout, which is readily cured with medication. I called the rheum consult and happened to be there when they came by to examine the patient. So I went in with them to see what I could learn. I had forgotten how much I liked rheumatology, haha.

2. I was able to answer most of my attending's questions without sounding/feeling stupid. This feels like an achievement for me because sometimes I feel like no matter how much I read, I fail to recall what the attending determines to be the most salient points. But today I was prepared (or at least phrased my answer in an acceptable way if I didn't exactly know the answer).

3. My attending gave me feedback on my performance. She told me how proud she was of my progress from day 1 to today. I went from an unsure and kind of shell-shocked student to someone who's confident and proactive in taking responsibility in my patient care. And I do feel like a different person since day 1 last week (I almost can't believe I've been doing this for 2 weeks already!). I chose the hospitalist service precisely because I knew my attending would throw me into the fray and force me to be an independent learner without training wheels, and I got what I wanted.

4. As such, my attending offered to write me a letter of recommendation for residency later! She told me how she's written LORs and how she's called residency programs to give her former students an extra edge. Now, when an attending offers to write a LOR, that means that the attending truly regarded you highly. I hope I can continue this momentum with future attendings on rotations down the road.

5. I met the city's oldest woman cop/detective! She quickly became my favorite patient (though she wasn't technically my patient). She was great to talk to. :-)
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Yesterday I hung out with Drew a bit. I picked him up from his house and we went to a coffee shop. We sat down and chatted and people-watched. He kept pointing out all the cute guys and guessing which were likely gay. Btw, I still don't get what people see in asses/what they notice about it; it's simply a body part that I rarely pay attention to. Someone enlighten me?

Anyway we had some good convo. He told me about this guy he likes and likes him back, but they both agreed that neither were in any position to date the other. I suppose that keeps the window open for me a bit, but Drew alluded to the fact that he just got comfortable being single again and would like to stay that way for a bit longer. I'll respect that . . . and also I couldn't get the right words I had wanted to say out of my mouth, lol. And I still couldn't get a feel if I even have a shot. Fail.

I did, however, manage to get him to take his shirt off in front of me. But I assure you it's for a legit reason. He had this rather nasty cough on and off as well as some sinus issues. I just so happened (unplanned, I assure you) to have my white coat and stethoscope in the back seat of my car. So he humored me in allowing me to listen to his lungs and heart. His heart sounded good but his upper lungs did sound a bit congested to me.

All in all, it's always great to hang out with him when we manage to align our schedules.

The One to Make Me Dance?

The dance by *klairy on deviantART

Today I drove about 4 hours to make it to my friend's wedding. In fact, my best friend from undergrad and my roommate freshman year. But more about that later when I've returned home and had time to process the pics I took a bit more.

I can't remember if I've mentioned this, but I always have mixed feelings during every wedding I attend. On the one hand, I'm really happy for the new couple and the potential of their lives together. But on the other hand, I'm also rather sad for myself and still being so so single. This is only accented during the dancing portion of the reception, which I utterly dread.

First all, I feel rather awkward with/in my own body (hands aside - years of playing the piano and cello have mediated that, lol). And second, I usually don't have anyone to dance with because I attend most of the wedding solo too; and if I did have someone to dance with, I'm also not sure what to do. It's all just a really awkward moment for me unless I've had 4+ shots of alcohol within the last 30 minutes or so, haha.

I'm still looking for that one person who can make me dance and not feel like an utter fool. Where is this person who can motivate me onto the dance floor and dance with them (or at all)? A part of me is sick of just sitting on the sidelines waiting. And a part of me is just too comfortable not exposing myself like that on the dance floor. I mean, I even feel embarrassed attempting to dance in the privacy of my own apartment!
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Anyway, on an unrelated note, Drew is now single. Again. Things didn't work out between him and his boyfriend and they broke up on friendly terms. It's been about 2 weeks since the break-up. In the intervening time, at least 3-4 guys have asked him out on dates, all of whom he had soundly rejected. For good reason! They should've given him at least 2 weeks to get over his last boyfriend - such quick rebound is good for no one.

But now 2 weeks are up. I don't know if I should make any kind of move while this window is still temporarily open. I don't want to be yet another guy asking him out on a date as I think that'd hurt our friendship (or at least make things a tad awkward in the future).

What I really want to do is just ask him if he'd ever consider dating me. And depending on his response I'd then ask him out (or not). But I also feel like it's cheesy to do that. Yet again, I don't want to be "yet another guy." Argh. What to do?!

I may ask him if he's free to hang out this coming Thursday afternoon/evening (because that's the earliest time during this week that I know I have some time off from rotations). I could ask him on the spot then. If he said yes things would actually work out nicely because I get my Step 1 board exam score this Wednesday, so he'd be either celebrating or commiserating with me depending on my score, lol.

He's one of the few people I've met who doesn't fail to make me smile and laugh when we hang out. I really enjoy spending time with him even as just friends. He may be one who can make me dance, lol. Argh, I don't want to mess this up. What should I do? Would things work out anyway since we're both so busy? :-/

Homunculus of Touch

Argh. Been feeling kind of defeated lately with these frustrating qbank questions. Overall I'm improving somewhat, but my scores are erratic - they spike up and then plummet and then spike again. Anyway, after studying neurology for the better part of a day, I managed to pull off a 71% on a block of neuro questions! Not sure how that happened, as I generally consider neuro to be one of my weaker areas.

Somewhat related, one of the most interesting things I remembered learning while going through neuro was the somatosensory homunculus. You see, sensation is unevenly distributed throughout our bodies and our brains form a somatosensory homunculus of it on the pre-frontal cortex. It's rather interesting. So think, what are the most sensitive parts of your body? Now look at the distribution of the somatosensory cortex:

Does it match what you thought? You'll notice that the face and hands are far over-represented. The fingers, lips, and face are more sensitive than pretty much any other part of the body. Do you notice the genitals? Hint: it's by the feet. Interesting that it comprises such a small part of the homunculus. A drawing of the somatosensory homunculus would be like this:

So I find it kind of funny how we put so much focus and attention on the penis and genitals. Yeah, sure, it's pretty sensitive given its body surface area (more so than, say, the legs), but it pales in comparison to the hands, lips, and face. One would probably expected the homunculus to be more like this:

Lol, right? Well, apparently, some recent-ish studies kind of hint that the homunculus actually is a bit more like this last version (the things you find on Google, lol). In 2005, Kell et al. attempted to update the somatosensory homunculus for males - chiefly that genital sensation is not near the feet in the somatosensory cortex, but closer to where it'd be on the body. In 2007, Sorrells et al. reported that 5 of the most sensitive parts of the penis is removed during circumcision (so it's curious, and incorrect, that the homunculus above is circumcised).

Of course, one has to wonder, what about women? It's been presumed that the number of genital nerve endings in men and women are about equal; however, there just aren't that many such studies out there done on women. There are numbers floating around in the internet (with no source that I can pin down) stating that the glans clitoris (basically the entire clitoris) has about 8000 nerve endings, whereas the glans penis (head of the penis) has about 4000; presumably, the other 4000 nerve endings are distributed along the shaft. Furthermore, the foreskin has about 10,000 to 20,000 nerve endings (and the clitoral hood somewhere around there but perhaps a little less).

What does all this mean? Who knows. Everyone experiences sensation different anyhow. Sure, there are objective ways to test sensation: 2-point discrimination, temperature, fine touch, coarse touch, vibration, etc. And there are different nerves that sense different things (apparently the foreskin has a bunch of the kind that detect fine touch and vibration). But what it all "means" is another thing entirely. I mean, though the hands are sensitive, they're not particularly sensual, am I right?

Anywho, I'm rambling. I hope you were entertained and curiosity piqued. :-P

Operation: Dragon

Blue Dragon. by *Amisgaudi on deviantART

Spring Break never lasts long enough. I only achieved about 1/3 of what I set out to do. :-/

Anyway, "Phase 2" will soon commence. Operation: Phoenix was a partial success, but now to begin Operation: Dragon. In many ways, it'll be similar to Operation: Phoenix only more intense, lol. Goals:

1. Be in bed by 12:45am (12:30am apparently was not feasible)
2. Wake up by 8:30am (8:00am apparently was also not feasible)
3. Continue the P90X program
4. Actually be serious about my diet
5. Buy a Qbank for the USLME Step 1 board exam and begin hardcore studying
6. Other

So I took a few pictures on Day 1 of P90X and like, Day 42-ish. I didn't think I'd see a huge difference but I was surprised! Now, I'm nowhere close to the amazing bodies I've seen people accomplish on the program, but the progress for me was visible (if only a tad subtle). I also apparently lost about 6-8 lbs, which was kinda surprising too. Unfortunately, I've kind of taken the last 2.5 weeks off so I'm going to restart the program from the middle of Phase 2 (instead of going right ahead to Phase 3). I'm hoping for better results this time around! (Sorry, no before and during pics for you all, hehe - still pretty self-conscious about that.)

As for diet, sigh, my body's stupid. -_- I just had my physical check-up at the beginning of the week and apparently, my triglycerides are about 2x normal. Everything else is good though. How does that happen?! o_O Apparently, I should eat fewer sweets, fewer carbs, and drink fewer alcoholic beverages. But . . . I don't eat that many sweets (generally), I don't eat that many carbs (usually), and I seldom drink. Granted, I did eat a lot of gummy bears when I'm at my friend's place in the last 3-4 weeks and I did have a few beers to celebrate a friend's b-day right before break, maybe that's the cause? Hmmm. Weird.

I've really got to get on studying hardcore for the board exam. Got to buy a Qbank and do 10-20 questions a night until May, at which point I'll have to kick it up several notches. Also, I must review my books for that exam a bit more in-depth now.

Lastly, Drew is on Spring Break this coming week and my week is fairly lax. Meaning, we will (somehow) find a way to meet each other this coming week. I've promised him a back massage, lol. I did also take a rein-check on a blowjob he offered like 3 weeks ago, but I'm not holding him to that (not right now, anyway). :-P

What Brings You In Today?

So I didn't do as bad on my pharm exam as I had feared. Not as well as I'd like, but it's an acceptable score. Moving on . . .

Physician 5 by ~stitchxwitch on deviantART

One of our courses this year is on learning how to take a history and physical exam. It is almost entirely what you make of it. I have friends who simply go through the motions of doing a physical exam and are almost unable to distinguish a normal heart sound from bowel sounds (a slight exaggeration). It is insufficient to simply go through the motions when, come July, interns and residents will ask us to do a physical on a patient and expect to trust our findings.

Last week I had a 71-year-old patient. He had a rather extensive history and an "impressive" medication list. I recognized and knew the mechanisms of action for over half the drugs he was on (because we were just tested on those drugs the day before). His physical exam was a bit tough (as for some reason geriatric patients are always tough for me). Being overweight doesn't help either. :-/

This week I had a 13-year-old patient. Have I ever mentioned how I love pediatric patients (insofar as doing physical exams)? I could hear her heart and lung sounds so clearly. Her reflexes were easier to find. I felt her abdominal aorta. I've never felt anyone's abdominal aorta before (because one has to be rather lean in order to feel it, unless one has an abdominal aortic aneurysm - in which case it's a medical emergency!). I finally figured out the ophthalmoscope and saw the red reflex and the optic disk in the back of the eyes. Looking in ears have always been rather easy for me - I even once got a 2-year-old with an ear infection to cooperate with me!

It is truly a privilege to be able to ask someone, "What brings you in today?" and "How can I help you?", and have them tell you something so intimate and for you to (hopefully) be able to do something tangible about it. It is a privilege that people allow us to touch their bodies in sometimes weird and uncomfortable ways to figure out what's wrong.

Come July, I expect myself to be able to do a physical exam to the point where I can, at minimum, tell a resident what is "normal" and what is "abnormal." Unlike my friend, I will not mistake a bowel sound for an abnormal heart sound.

P.S. I've really got to get myself a clipboard.

You've Gotta Go Deeper

A few weeks ago I posted my recount of the female pelvic exam. So last Thursday I walked over to the urology clinic with other med students to do the male genitourinary exam. This is what you've all been waiting for, lol. But . . . it was rather anticlimactic.

So we walk over to the urology clinic, which is (curiously) in the lower level of the hospital. We were to examine a male standardized patient in groups of 4-5 with a resident or an attending physician. My group got this really nice and laid back resident. I especially love his preface with something like, "You know, urology is great. I never thought that I'd be doing what I'm doing, but I love it. As long as you can explain to your kids why you're not a pervert, and explain to their parents why you're not a pervert, then you're good to go. And within medicine, it's a highly highly respected field."

Some more chatter to relieve the inevitable tension of the situation (though less tension than for the pelvic!), and then we enter the tiny exam room. Sitting in our room was a guy in one of those hospital gowns. As soon as he lifted his gown, we noticed all his tattoos and he looked like your stereotypical biker guy (beard and all!). He later told us that he uses the money from doing these things to get more tattoos, lol.
So as with all exams, it begins with inspection. Some things to note: circumcised or uncircumcised, symmetry, and anything "weird" (lumps, bumps, sores, etc). This part is so important that the resident told us that if we were to ever consult urology after doing a male exam and didn't note whether the guy is circumcised/uncircumcised, then they think we didn't really do a male exam. Our guy was circumcised (unlike the prototypical picture above, and unlike 70-80% of guys on the planet - but still pretty common in the US).

Next was palpation. So basically, just feel along the penile shaft for any lumps/bumps that can't be seen, and gently open the meatus of the urethra (pee hole) to make sure nothing's wrong there. Note that it's "patent."

Then examine the testicles. There's a particular technique to "trap" the testicles between the fingers so it's easier to feel without causing (much) discomfort. Feel for lumps/bumps, find the epididymis, the spermatic cord, etc. Ask them to cough and then feel for any varicoceles.

And finally, do a hernia exam. This was actually a tad tricky, because you have to follow the spermatic cord back into where it goes into the body (and it's not as easy as it'd necessarily seem) and then ask them to cough. Our guy had to constantly tell us whether or not we were in the right area. Often he'd say something like, "You've gotta go up and you've gotta go deeper." Yeah, that was a bit odd, lol.

We didn't do a prostate exam on him. Instead, everyone did a prostate exam on a plastic model. Eh, chances are I'll never really need to do one anyway (in peds), so whatever.

And that's that. Clinical, short, easy. Like I said, rather anticlimactic and not very exciting. Our guy could've used some lotion on his penis, it looked rather dry to me (especially the glans). ::Shrugs::

On the Wings of Progress

Well, it's been a while, hasn't it? My apologies.

You see, my life is nothing if not busy (even if being busy means playing a video game when not studying . . .). Much has happened since I last posted here, too much to cram. Most important is that which ride on the wings of progress.

Right after my last exam, I had a meeting with the Dean of Student Diversity here. She's by far my favorite dean to work with. We discussed what changes need to be implemented to make the medical campus more LGBT friendly and promote diversity in general. Some key issues included: admissions, visible signs to show tolerance, improving the curriculum to better meet the needs of a diverse patient population, recruit more diverse standardized patients, and anything necessary for the new medical educations building (e.g. a unisex bathroom for transgender people). I left with a very positive feeling that things will change, that things will improve.

Later that week, I met with some students to write resolutions to be presented to the state medical society (the body that governs the practice of medicine within each state) that focused on LGBT. One resolution I helped write was to edit an existing resolution in order to include "sexual orientation" and "gender identity" in hospital non-discrimination policies across the state (because "gender" isn't the same as "sexual orientation" and "gender identity"). Another student wrote a resolution to promote anti-bullying programs in K-12 schools.

And now for a couple things I came across on Facebook earlier this week:

Gay Marine's husband surprised at respect shown by Naval Academy

Zach Wahls speaks about family

This is quite a moving and powerful speech he gives.

---TANGENT---
So I'm still doing the P90X program. I'm about halfway through the 4th week. I haven't seen (or felt) that many changes. I suppose my arms are a tad leaner, my legs a bit more muscular, I'm a bit more flexible, and you could perhaps see the shadow of abs underneath the flab. That's about where I'm at right now. I've found the "yoga" and the "ab ripper x" particularly difficult. Yoga because it's just so long (I haven't been able to complete it from start to finish yet)! And the ab exercises are just so difficult that I simply can't do the number of sets at the speed that they go at. :-/
---END TANGENT---