The Adventures Continue

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

1.  Senior Resident

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

2.  Fellowship Interviews

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

 Cincinnati, OH

 Pittsburgh, PA

Ann Arbor,MI

Seattle, WA

3.  Another Away Rotation

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

4.  Match Day

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

5.  (Lack of) Social Life

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

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.

Where in the World is Aek?

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

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

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

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

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

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

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

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

The Fastest Longest Year

hospital floors by JESSERZZZ on deviantART

Farewell to intern year, the fastest longest year ever!  It's certainly been a crazy ride full of up and down roller coaster emotions.  And boy did the year finish with a bang!  Time to muse on a few thoughts:

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1.  Doctors incognito

I've noticed an interesting trend among us "newer" physicians: we never let anyone in public know that we're doctors.  At least not initially.  We never introduce ourselves as doctors, we never use our hard-earned titles in public, and when asked what we do for a living, we'll say something along the lines of "I work in the medical field" or "I work in the hospitals," but almost never will we say outright "I'm a resident/doctor."  Why is that?

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

As such, I'm never offended if someone calls me "Mr." instead of "Dr."  Although, an interesting thing to note that in Britain, "Mr." is a title ascribed to surgeons whereas "Dr." is a title ascribed to physicians.

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2.  The misunderstood adolescent

I may have said this before - I'm one of the few pediatricians who actually enjoys interacting with teens.  Not all teens, mind you, but in general yes.  Anyway, this bodes well especially if I'm really intent on pursuing peds rheumatology (which skews heavily toddlers and teens).

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

Anyway, there are 3 things I always iterate to every teen guy: 1.) wash under your foreskin (most of them where I am are uncut - good for them, lol), 2.) monthly testicular self-exams, and 3.) ALWAYS USE CONDOMS.

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3.  Rising seniors

As interns we are the lowest person on the totem pole that matters (sorry med students, the hospital functions very well with or without you).  We're often abused - intentionally and unintentionally - by senior residents, attending physicians, nursing staff, etc.  It's a frustrating place to be.  But at the end of every intern year is the promise of becoming senior residents and FINALLY stepping out of the intern role.

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

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

Please Don't Misunderstand Me

Please don't misunderstand me, I do love seeing my patients even though for every minute I see them I have 5 minutes of paperwork and other "work" to get things done for them.

Please don't misunderstand me, if I can't make it to your bedside immediately it's not that I dislike you or am lazy, I truly am quite busy doing things behind the scenes for you or another patient.

Please don't misunderstand me, as much as I love thinking and taking care of patients, I lie here right now musing over whether I've made the right choices that can sometimes be literally life or death.

Please don't misunderstand me, if I seem beaten down it's because I've worked a 13+ hour shift for the n'th day in a row often without a single heartfelt thank you. And perhaps I was yelled at for something I did or didn't do for you.

Please don't misunderstand me, as much as I could go back in time and undo med school and residency, it is truly a profession of great privilege and honor.

Please don't misunderstand me, when I say I would not redo all this again it's not out of regret, but rather sadness of all the sacrifices I've made - the art I missed drawing, the music I missed playing, the sleep I missed getting, the opportunities for love and travel.

Please don't misunderstand me, when I discourage others from pursuing medicine it's not because I hate my job, but rather I don't want others to make the same sacrifices without truly appreciating what they'll be giving up.

The Truth Is . . .

medicine by bloodred on deviantART

I attended the pediatric rheumatology conference earlier this month.  It was like a mini-vacation and I learned so much!  My mind was blown at how much there was out there (and how little I knew).  I ran into a resident who's doing her residency back where we did med school, so that was a pleasant surprise.

I just finished my clinic month, which was mostly urgent care.  It was useful and my Spanish got exponentially better (because I refused to use the translator phones after a while, and like 2/3 of the parents speak Spanish-only).  But it was really bread-and-butter and much of it didn't require much "thinking."  I hate to say it, but an NP or PA could easily do what I did this month without much difficulty.  It doesn't surprise me that NPs are trying to expand their "power" and scope of practice.

But the most brutal truth is: if I could go back in time, I would NOT do med school and residency.  This is not worth it.  As much as I love my patients, as adorable as my toddlers are, as amusing as my teens are; the hours, the hospital politics, the paperwork (oh god the paperwork!) is not worth it.  I daydream of what I've given up to become a doctor.  It's not a career I'd recommend anyone pursuing.  And that's the most brutal truth.  Perhaps I'll elaborate on this more later.

I came across the following coming out video and the way the person spoke, the honesty and anxiety in his voice, really resonated with me.

Apologies that this post is all over the place.  I'm on call tomorrow (again, yay) and have to do yet another 13-hour shift.  At least I'm on with good residents who I admire and respect.  The day should hopefully not be too painful.

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.  :-)

Janus at the Gate

Janus by ~luka-basyrov-art on deviantART

Janus, the Roman god of Gates, whose two faces look towards the past and the future, and for whom the month of January is named after. An very interesting and apropos Roman god for the new year. 

2013 has been a year of ups and downs. Meeting new friends and saying farewell to close ones. A year that marked the end of one era and the beginning of the next. One filled with pride, accomplishment, and excitement. One full of anxiety, doubt, and frustrations. A year I would do all over again and yet would never wish it repeated. 

I left 2013 and entered 2014 on not the best of notes (what with issues with my student loans servicer and a laptop that's crashing far too often). And least of which I was working on both Christmas and New Year's (actually at work now). What kind of year will 2014 be?  Surely one we make, right?

Lately I've been left feeling so out of balance and it's difficult to find the way back, much less time to look for the way. But 2014 needs to be a year where I can center myself, refocus my energy, find my motivation, and let the wounds of 2013 scar over. Time heals all wounds, but the scars they leave serve as constant reminders of what was. 

I have no particular resolutions. I'd just make the same ones as I do every year. Eat healthier. Work out more. Lose weight. Find love. Explore more. Travel more. Easier said than done when I'm still figuring things out day by day, week by week. 

I do not mean this post to be a depressing one. I am a realist, and reality isn't rose colored. There are some positive things to look forward to this year. In many ways, after the first couple months there is only up. But I must not rest my laurels, vigilance is still needed.

If I am so lucky, so bold, maybe - just maybe - I can achieve some that which I hadn't been able to for several years now. Let the new year begin!

Last Man Standing

Last Man Standing by *Cute-And-Bright on deviantART

Yeah yeah, I know it's been months since I last posted.  In my defense, it's been such a crazy ride I don't even know where to begin!  This residency thing is no joke, with all the days that I just want to break down and punch a wall.  To anyone contemplating medicine, my advice is: do not do it if you can see yourself doing anything else with your life.

Anyway, I've basically been on 5 inpatient rotations back-to-back, starting with NICU, then wards, then 4 weeks of night shift (6:30pm till 8am), then back to wards, then to newborn nursery (which, despite the benign-sounding name, has inpatient hours - 6:30am till 7pm).  That's basically 5 months straight of working 13-14+ hours a day, averaging 6 of 7 days a week.  I've had to work 19 days straight twice already!  Those 19 days are brutal.  And even that's an understatement.

At the end of each day I'm just exhausted.  I barely have time to take care of errands, much less myself!  My chief residents wonder why I don't feel "happy and excited to go to work every day."  Gee, it's not rocket science.  If you basically work twice the "normal" 40 hours/week and have half the number weekend days off in a month, would you be happy and excited even if it's something you love doing?  Likely not, I think.  It's not that I don't love my patients and families - I do.  They're why I haven't quit (well, one of many reasons).  And there are rare moments of joy in my day, but it's so hard to really feel "happy and excited" when it feels like you're just nose to the grindstone every single day.  At least I'm not a surgery resident . . . I'd probably have quit or committed suicide by now.

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On another depressing note, I think I may have lost a friend.  Even back in June I hadn't chatted with him in like a month or so.  Now it feels like all communication has been cut off.  He doesn't respond to Facebook messages, texts, IM's (actually, he doesn't even show up on IM or Skype anymore, leading me to think he has either deleted or blocked me), Tumblr messages, etc.  A couple weeks ago I noticed that he unfollowed me on Tumblr and blocked me, such that none of his posts showed up on my dashboard.

I'm at a loss for words and thoughts.  I don't know what I did.  I know he has a boyfriend who he's quite involved with, is busy with school and work, but it just doesn't explain why he doesn't respond to any mode of communication.  I even called him once or twice and left a voicemail.  I don't know what to do.  I haven't really tried to communicate with him much over the past several weeks, to give him some space.  I'm just at a loss as to why he cut me off like this in the first place.  Maybe it's partly cuz of what we did when we met in person, and given he has a boyfriend now?  Idk.

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On a happier note, I was lucky to have Thanksgiving off so I could go visit my family (I work both Christmas and New Year's).  It's always nice to see my grandparents and my little cousin.  It's such a world removed from work.

And now I'm on vacation visiting my brother in Texas for a few days.  Huzzah!  It's nice to sleep in.  :-)  I'll try to find time to post some pics later this week when I return to my apartment.  After 5 blocks of inpatient rotations back-to-back, these 2 weeks of vacation are sooooo well-deserved.  And I fear it'll fly by quicker than I can blink . . .

I Survived . . .?

I survived by ~CasheeFoo on deviantART

Somehow I survived my first block of wards (and my second inpatient block, the first being NICU).  Wards is basically what you would imagine hospital medicine to be like, the kind of thing you see on "House" or whatnot.

The first day I was handed 6 patients I knew nothing about, one of whom was a cluster-fuck of complicated medical problems.  The rarity and severity of her illnesses terrified me.  Within a day or two I was expected to know her inside and out.  I was literally running around the hospital trying to figure my way around and see all my patients before meeting with the rest of the team for rounds.  This was far worse than any experience I had as a med student, because as a med student you're still under the aegis of your resident who protects you - more than I had previously appreciated.  And oh yeah, I had to basically learn an EMR (electronic medical record) and use it by the end of the first day.  Not cool.

I felt so overwhelmed that by the end of the second day I was ready to throw the laptop I was working on out the window and run out of the hospital screaming at the top of my lungs and quit on the spot.  I somehow, not sure how, held it together.  The med students arrived the third day.  I held it together.  For them.  I could not show my weaknesses in front of them - I had to give them the impression that peds was a great field (it still is).  Luckily I had inexplicably hit my stride as well and starting doing alright after that.

Having a med student by my side did wonders for my morale.  I'm not entirely sure why.  I guess I just wanted someone to talk to and bounce diagnostic ideas off of who won't judge me or think I'm an idiot.  Also once I discovered the most efficient path forward for me, nothing stops me.  As a med student I really struggled with finding that path, as it's not a med student's job to be efficient.  On the contrary, med students are supposed to be exceedingly thorough.  My sub-I as a M4 student kicked my ass, but in hindsight I was only able to survive wards now because of that experience.  I dare say I became the most efficient of the 4 interns on during this block.

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In other news, guys here kind of suck.

I've been stood up on a couple dates or otherwise had plans change/get delayed.  It's okay if you're going to be 10-15 min late, but 2-3 hours?!  Come on, that's just rude.  Makes me want to give up looking (as if I had the time anyway, ha!).

Been chatting with a few people, hopefully something goes somewhere.

All the Babies!

Sorry for the lack of posting, it's been quite hectic (but manageable, sorta).

I just finished a block of genetics subspecialty outpatient clinic.  Genetics is a fascinating subject as always, and I must say, this block reignited some of my former interest in the field.  I'm not sure if it's enough to make me want to pursue it as a fellowship and career, but it's back on the radar, lol.

In the middle there I did a week of nights.  I got pretty good at assessing normal healthy newborns, haha.  But man there's such a learning curve when you haven't done it in like 2 years!!  I was lucky enough to get some sleep most nights, but the schedule of nights (6:30pm to 7am) is still rough.  Takes a while to adjust and adjust back.

Now I'm in the NICU (neonatal intensive care unit).  I was terrified of it at the start, but it actually turned out to be a really nice rotation.  I'm definitely learning a lot about taking care of premature babies, often with other health problems too.  After a while they mostly become "feeders and growers," that is they're just eating to gain enough weight to go home.

Anyway, up until now, the majority of my experience has been with babies.  All the babies!  Haha.  They're pretty cute, I must say.  One just has to get on the good side of their territorial and protective nurses, lol.

I've had the privilege to see some weird and rare things, which is really cool.  I mean things that we should not be seeing because current routine medical care should have picked up these things earlier, but there are always babies that slip through the cracks.  It's quite unfortunate when a baby could be otherwise perfectly normal and healthy sees us and by then it's too late to stop the worst of it.

Anywho, enough rambling.  Must sleep.  6:30am to 7pm schedule is pretty rough too.  Unfortunately that's my schedule for the next several months . . .  As one of my senior residents said to me, "Oh wow, I'm sorry.  But the Lord doesn't give us more than what we can take."  I hope she's right.  Still, I'm soooo glad I'm not a surgical resident.

An . . . Interesting Start

A few updates are in order I do believe, lol.

1.  Moved across the country!!  Changed my driver's license, car registration, and car plates to this new state.  All within 3 hours (the DMV lady who helped me was SUPER understanding and helpful).

2.  Visited my relatives!  I had my car shipped to my grandpa's place ahead of me so I didn't have to drive across country.  That would've been brutal!  Visiting relatives is fun, I like hanging out with my little cousin here.  My grandpa is just now really seriously starting to push that I be in a relationship and hopefully marry in the near-ish future, before he gets too old and such . . . sigh.

3.  Moved into a new apartment!  It's nice having a 1-bedroom apartment to yourself.  I actually think this apartment is somewhat larger than my old 2-bedroom, 1.5-bath that I shared with my roommate in med school for 4 years, lol.

4.  Met my co-interns!  My co-interns are all super nice and funny people.  And they don't take themselves too seriously, which is good considering we're all pediatricians, haha.  Definitely a group I can see us bonding together and hanging out with during our (borderline non-existent) free time.  Only thing is that most (all?) of them are either married or in long-term relationships, so the significant others will be a major factor in our social gatherings.  I really need to get on that . . .

5.  Had an . . . interesting start to orientation.  We had PALS (pediatric advance life support) training the first 2 days.  On the first day, 6 of us (half the intern year, mind you) came back from lunch about 5 minutes late and the mean stickler instructor lady refused to let us back in.  She told us we had to reschedule and pay for it out-of-pocket . . . that's $250!!  She was totally being unreasonable.  Our program coordinator tried her best to help us sort out the situation and when the Chair of the Pediatrics Department found out how poorly she treated us, he was furious.  It's likely that the program won't be using them next year . . .

6.  Haven't talked to my friend (mentioned in post here) for a LONG time.  I miss chatting with him.  He's out of school for the summer and started a summer job that leaves him tired at the end of the day.  I frequently see him online for short periods of time, but he rarely responds to my messages or texts anymore.  In fact, we haven't chatted in almost a month!  Not for a lack of trying on my part.  I know he's also busy with a few other things, including hanging out with his close friends who're also out for the summer, but still - it kinda hurts.  It really does feel like he's ignoring me as much as he can.  I've decided to just back off for the next few weeks/months and see if he comes around.  Hopefully so, because I do miss chatting with him.  :-(

Phew!  I think you're more or less up-to-date now.  Why're all the girls I'm interested in either married or in long-term relationships, and all the guy's I'm interested in so far away (aka another state/country)?!?!  Sigh.

I Matched!!

Wow.  What a day.  The Ides of March.  Match Day.

It's been a crazy ride.  I'm SO glad that my med school doesn't make students read where they matched out loud to the entire class.  So many people would've completely broke down crying (in joy or sadness).  Instead, my med school puts all the match envelops in a bin and chooses out names at random.

As each of my friends go up to get their results, I see their faces downcast as they matched their 6th or 8th place.  Finally one of my friends matched her #1 and I was called shortly after.  I was SO nervous - like nauseated and heart palpitations.  Imagine my (shock and) surprise when I matched at my NUMBER TWO rank!!  :-D

It's not my #1, but it's (obviously) the next best.  I had psyched myself up for my #1 so much in my head that really almost all of my other ranks paled in comparison, which is unfair.  It's unreal.  Even now I can't quite believe it.

Actually I'm starting to have irrational doubts now.  Will I be okay with the culture shock of moving so far away?  Did I make the right choice in the order of ranking my programs?  Did I lower myself as a candidate for not ranking more "prestigious" programs higher?  Will I have the time and energy to have a social life outside the hospital?

Like I said, irrational.  In retrospect, this may be the perfect match for me, even though it's #2.  It's a smaller (but not "small") program without fellows, and so more attention can be paid towards teaching me and mentoring me.  It still has all the sub-specialties represented and is a free-standing children's hospital - so my training is automatically solid.  And it's still in the state I want to be in (albeit not quite in the area of the state I'd prefer to be in, but that's okay).

It was a tough match this year.  Lots of disappointed people who applied to a surgical programs, or even medicine programs.  The number of American med school graduates keep growing, but the residency slots are static (some programs may even have shrunk a little as a consequence of the crap going on at the federal government level).  It's only going to get tougher but at the end of the day, most people match, which means most of us will become the clinical doctors that we went to med school to be.

In about 2 months, I will have an MD and have a spot as a pediatric resident.  :-)

Check & Check

Step 2 CK: check. (Did 20 points better than on Step 1, woot!)

Step 2 CS: check.

Letters of recommendation: check.

ERAS application: check.

Schedule my first few residency interviews: check.

Haven't actually gotten a residency interview invitation in a while now, and it's making me nervous.  I applied to 29 programs, which most people have told me is overkill for pediatrics (on average, people applying to pediatrics apply to about 15-20 programs).  I really need to hear from more programs NOW.

I'm on pediatric anesthesia right now.  For the past month I've been on my vacation month (for another post), so coming back to starting at 6:30am is a bit of a shift.  It's been a good experience so far.  I like getting the opportunity and practice of putting IV's in babies and kids, as well as manage the airway.  I like being able to see a diversity of pediatric surgeries because I can migrate from OR to OR each day and see something totally different than if I were just on one surgical service.  Everyone I've interacted with has been very nice and (usually) patient with me.

But I have to say, some people have got to stop trying to make me question why I want to do pediatrics.  Yes, I will be making about 1/4 to 1/3 of your salary.  No, it's definitely not for the money, that's abundantly clear.  I'm well aware that I'll be making among the bottom salaries as far as physicians go.  That said, I will make more money than both my parents' salaries combined.  And I see absolutely no need to "upgrade" my lifestyle.  Yes, I will come out with far more debt than both my parents, but I don't doubt that I'll have the ability to pay it off (annoying rough as that may potentially be).

Anyway, there were some cases I've seen that have definitely reaffirmed some of the reasons why I choose to pursue pediatrics (for another post).  And who knows, if I get bored or burnt out, pediatric anesthesiology might be an option, as it seems almost 1/3 to 1/2 of the staff peds anesthesiologists here apparently started off as pediatricians.  Hmm . . . I must pick their brains on this.

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

Another Step Taken

Another step by ~F1rstcl4ssn00b on deviantART

Step 1: check.

Step 2 CK: check.

Check off each step taken towards my medical license.  Hopefully I passed Step 2 CK, but I won't definitively know for almost a month.  Blah.  I shudder to think about retaking that 9-hour long test (not to mention how much it costs!).  With some luck, I did markedly better on Step 2 CK than on Step 1 last year.

Steps left to go: Step 2 CS and Step 3.  After that, it's just the re-certification exams every 10 years to be board certified.  Yay.  Endless testing.  -_-

But for the moment, I have a short window of freedom (and a short vacation coming up!).  So I'm going to enjoy this while it lasts.  Alas I also have to work on ERAS applications for residency programs.

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.

Ending with the Crazies

Ya know, I could say how I've been busy and whatnot.  But that'd be a lie this time.  I've just been lazy.  The year has been winding down for some time and I just couldn't be bothered, lol.  And as it is, I end the year with the crazies (aka, psychiatry).

It actually wasn't a bad rotation.  Spent 2 weeks on child/adolescent psych, 1 week on eating disorders, and 1 week on adult psych.  As the director of the place told us several times, "Most of these patients ain't dumb, they ain't crazy, they just have had crazy things happen in their lives and couldn't handle it, and that's why they're here."  On about day 3 I realized how true his words rang.

The vast majority of psychiatric patients I saw aren't crazy.  Most of them aren't schizophrenic, they don't hear voices other people don't hear, they don't see things other people don't see, they aren't foaming at the mouth or anything (that said, the couple of schizophrenics who weren't taking their medications really were sometimes kinda scary crazy).  Most of the people I saw actually had mood disorders - anxiety, depression, irritability, etc.

The best way I can describe most patients' situations is that crazy things happen in their lives - a kid is witness to domestic violence or is abused (verbally, physically, emotionally, and/or sexually), a teen feels out of control when her parents divorce and start restricting her eating, an adult couldn't handle the pain from multiple surgeries and turns to drugs - and their minds just can't take it.  Something inside breaks and they snap.  These people try to resolve things and find an outlet for the trauma of their minds and find themselves repeatedly bashing their heads against a proverbial wall.

And when they're at their lowest, when there's not much further down to go, they come to us at an inpatient psychiatric hospital.  Here we control the environment, take the responsibility out of their hands for a time, talk to them, counsel them, prescribe medications.  And these medications often work (it may take some fiddling around to find the right drug and dose for the right person, but it works out more often than not).  They kind of reset the imbalance in the brain and allow people to think clearer, calmer, and more rationally.  They smooth out the edges of emotions so one doesn't soar as high or dip as low.

Mental health.  It's a real thing.  Sometimes all one needs is some counseling, and sometimes it requires medication.  In that regard, it's not really any different than diabetes or hypertension.

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Oh yeah, I'm 3/4 of an MD now!  :-D  Unfortunately the other aspects of my life have been less interesting than the things I witness when I'm in the hospital.  Still a few things here and there worth blogging about in posts to come.

Oh yeah, PPACA (aka, Obamacare) survived the Supreme Court ruling.  Thoughts?  Also for another post, lol.

The Past Few Months

It's been a while since I last blogged.  I could easily claim that I've been busy (which I have), but it's just as much my fault for being lazy.  Blogger has changed in this interval time (I kinda like the old version better, lol).  I've seen and learned a lot these past few months in the various rotations I've circulated through.  Each month presented a different slice of medicine.

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Family Medicine

Truthfully, this was easily one of my favorite rotations.  I worked in a clinic with a preceptor, no residents on site, and I got to do a lot.  It was almost like a continuation from outpatient pediatrics the month prior and I loved it.

Family medicine is the "jack of all trades, master of none" field insofar as it sees the full spectrum of ages and patients, and can do a little bit of everything but is unable to narrow down into most sub-specialties (e.g. cardiology, pulmonology, etc).  But you see the bread-and-butter of everyday illnesses and do things like lance boils, freeze warts, do a little physical therapy, and things like that.

But the one thing I most took away from family medicine was my preceptor's outlook on life.  He spent his career nurturing his perfect work-life balance, and it was something he reiterated to me over and over again.  He didn't mind earning a little less money than the other physicians in the practice because the flip side was that he got to spend more time with his family and kids.  It all comes down to priorities.

One life philosophy that was parroted by his son one day is, "Have a good day, or not.  The choice is yours."  And he told that to more patients than I could count that month.
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Pediatric Infectious Diseases

Peds ID was something I was almost certain I would do coming into med school.  My background almost perfectly set me up for it - a year of public health, focus in genetics and molecular biology, interest in HIV/AIDS, etc.

But then something curious happened.  I loved outpatient pediatrics.  I loved family medicine.  I loved pediatric rheumatology.  I could no longer choose or peg myself down for something so narrow as pediatric infectious diseases with a focus in HIV/AIDS.  I found myself wanted to become more general.

That said, I still enjoyed the month.  I got to know my patients in the hospital (they didn't always know me, several of them being babies or else mentally handicapped).  I got to understand the work-up for an infectious etiology.  And every Wednesday at the weekly conference where all the staff physicians in peds ID got together to discuss the treatment plans for all the patients on service, they would all go at each other.  It was one of the most entertaining, and intellectually stimulating, things to sit through.  I was entertained, anyway.

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Perioperative Medicine

Aka, anesthesiology (with bits of trauma and emergency medicine tossed in).  I knew I'd like this rotation.  I liked doing things with my hands and doing small procedures (not surgeries though).  I didn't expect to love it but I did.

In anesthesiology, you put patients to sleep in the OR (operating room), keep them alive throughout the surgery, monitor pain, and wake them up.  Your job is one of the most important jobs because you are directly responsible for someone's life.  You control every aspect of their physiology - their breathing, their heart rate, their muscles (via paralysis), and their consciousness.  My resident asked me, "Who is in the best position to kill the patient?  The surgeon?  No, it's us, the anesthesiologist.  Without us the patient can't breathe.  And if we make a mistake with a medication, the patient may never wake up."

There was a sense of immediate gratification and power in anesthesiology.  I got to put in several peripheral IVs (didn't miss a single one I'm proud to say).  I really liked putting in IVs . . . I got to monitor and chart the patient's course in the OR.  I got to breathe for patients.  I attempted to intubate a few (intubation is quite difficult for me, grrr).  I got to help prep and push drugs that slowed a person's heart rate down when it got too high, or boost a person's blood pressure when it dipped too low, or reinforce paralysis when a person began to twitch in the middle of surgery (always under the direct watchful eye of a physician, of course).

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Obstetrics/Gynecology

I . . . didn't really like ob/gyn. I mean, it was okay.  Not as brutal as surgery.  I just don't think I could stand women and pregnant women all day.  The vast majority of the residents are women as well!  That said, I did like participating in vaginal deliveries.  Got to catch a couple babies too!  They're just as slippery as you'd imagine.

The one thing I REALLY disliked about ob/gyn is that you spend almost zero time with the baby once it's out of the womb.  You hand the baby off to the nurse or the neonatologist and don't bat an eye at it again.  I found myself lingering more at the baby's side than the mom's.  Yeah . . . it's a sign.  Babies are so cute (even right after they're born and are all slimy and malformed-looking)!!

One other thing - you don't truly appreciate blood loss until this rotation.  In surgery you think you've seen someone bleed during surgery.  Just wait until a birth or better yet, a C-section.  A woman is expected to lose one liter of blood during that procedure - one liter!  The vast majority of women do just fine afterwards though, because their bodies have spent the better part of up to 9 months prepping for that loss.  Still though . . .

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Neurology/Psychiatry

Well I just finished neurology and will be starting psychiatry tomorrow.  Neurology was okay.  I was on an awesome team with great residents and good attendings who taught quite a bit.  But I saw a very small slice of neurology as I was on the neurovascular (aka, stroke) team.

We saw many patients with strokes or suspected strokes.  The neurological deficits are interesting to see when they're there.  What's nice to know is that most people recover and do just fine after a relatively small stroke.  It's the large ones that really take out half your body that're devastating.  There were a few devastating strokes on our service in our short time there.

So public service announcement: exercise some, eat healthy, take your blood pressure/high cholesterol medication if you need them, do not smoke.  A stroke is a scary thing to have happen to you, especially when you're young (less than 65 years old).  There are a lot of things we can do to reduce that risk.