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.

A Sudden Farewell

At around 10pm on May 1st, one of my closest friends committed suicide.

I learned that fact from his older brother on Facebook.  There were and are no words that adequately describe my shock.  There are so many questions left unanswered.  What warning signs there were (if any) were subtle.  But this much I do know.

My friend, who had a promising career in directing/acting, went to Los Angeles in December to seek career opportunities and to "find himself."  From piecing together snippets of conversations from several of his friends, his brother was able to figure out that his mental state had begun to decline.  While in isolation each of the conversations he had with people were nothing out of the ordinary, together they may have foreshadowed this event.  In fact, even earlier on May 1st he had lengthy and rather ordinary conversations with people, including his brother.  Such is the curse of hindsight.

I have promised his brother not to say much more, at least not until after the funeral.  I have an unfinished document sitting on my laptop that I had meant to send him - a document that he will never be able to receive.  We didn't talk too much these days, because of our very busy schedules and the distances that separated us.  But he was a friend I had known practically my entire life.

My last memory of him was at his brother's wedding back in September.  Although it has been months and I wasn't able to talk to him and say another goodbye, it was good seeing him back then and he shall remain in my good memories.

Farewell, my friend.  You will be missed.

The Truth of the Matter

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

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

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

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

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

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

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

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

Return from Unexpected Hiatus

Wow, hard to believe it's been a month since I last posted anything here! Also kind of hard to believe that I haven't been blogging about all the things I've seen and done the last 3 months (and there's oh so much to tell). Didn't mean to not post . . . oops.

Days have become long again, now that I'm on ob/gyn. It's an abomination to wake up and be at the hospital before dawn. Thankfully, the break of dawn is slowly creeping earlier and earlier in the day such that by the time I get to the hospital, the cracks of daylight begin to alight the horizon.

But before I get back into my day to day, week to week, month to month recount, there are 2 things I came across on Facebook recently.

On Being Gay in Medicine: A Leading Harvard Pediatrician's Story
This is an amazingly written (albeit long) article. The author recalls how when he was in med school, you had to stay closeted otherwise your career can be ruined at a whim. It's almost weird reading about that and about how much things have changed. Things are getting better, but there's always some room for improvement. I think this article resonated with many people, gay/bi/straight/otherwise.

It Gets Better at Brigham Young University

This is a really touching YouTube vid I saw posted. Very well done (albeit long-ish) and very moving. It's not secret that BYU is among the least LGBT-friendly campuses in the nation, but it's reassuring to know that even there things are changing for the better. Definitely worth watching the whole thing.

Chosen Path

This post is actually 2 weeks later than when I made my decision, but it has to be written nonetheless.

I've decided that I will not return and finish my MPH.

It's not like I'm necessarily giving up on getting an MPH (eventually), it's just not what I'm looking for in my career at this time. I may end up getting an MPH as a part of a preventive medicine or ID fellowship, if/when that time comes. I may end up coming full circle and return to some lab work, but not now and not in the near future.

And I've decided this for the reasons I wrote in my previous post. The words that clarified my decision came from my M4 advisor, who told me:

"I'm going to tell you what I tell residents who're deciding whether to do a fellowship or not. A fellowship, like your MPH, requires you to give it your all and your total dedication. If you're going back and forth now, ask yourself: is this really what you want? Or is your doubt telling you something?"

Those words shone in my mind like a sun burning up morning fog. I've made my decision. And I'm at peace with it.

Uncertain Crossroads

Crossroads by ~Nadja18 on deviantART

Last week my application for re-admission to complete my MPH (Master's in Public Health) was approved. Initially I was ecstatic because I had been talking about this moment for over a year, about how I loved/valued the program, etc. Now for the past week or so, I'm not so sure - I've been getting some cold feet and doubting whether I will actually go back and finish what I started. The conviction which I had held for the past 1-2 years is gone. And it all hinges on "uncertainty."

I am uncertain that:
1. I will get funding to finish my MPH (I do NOT want to tack on any more to my growing student loan debt).
2. I really need to finish my MPH to do what I want to do.
3. I still want to do what I had originally set out to do when I began med school.

Here's how those primary uncertainties are being addressed at the moment. 1.) I stand a fairly decent chance of getting funding via teaching undergrad courses as a grad student. It was reassuring that the professor I taught for was very willing to write me a letter of recommendation and remembers me so well. 2.) I do not need to finish my MPH to do what I want to do. Would it be useful? Perhaps, but it depends on what I end up doing. Which brings me to, 3.) Without even realizing, I've changed. I had set out to be the so-called "triple threat," that is the doctor who sees patients, does research, and teaches students. Now I'm not so keen on the research bit, haha. Also I had set out to do ID (infectious diseases), and while that's still on my career list, I've begun to shift away towards primary care or another specialty like rheumatology.

My MPH degree is very specific towards a particularly ID-oriented skill set. With my degree I would be better equipped to understand infectious diseases, conduct laboratory "bench" research, and create surveillance programs relating to infectious diseases and the agents to treat them. And prior to med school, that was one aspect I had wanted out of my career. Now I don't know.

Now a few things are certain and have remained certain (if not strengthened) over the past several years: 1.) I want my career to be clinically focused on treating patients. 2.) I want my career to have a public health/community engagement component. 3.) I want to teach students (doesn't have to be med students). 4.) I want a good work-life balance. None of those require an MPH - or more specifically, my focused MPH program.

So I'm in a bind. Will I regret later down the road for not having finished my MPH? If I get my MPH and never end up going into an ID field, will I feel like I "wasted" a year? I can see myself going either way, and neither road is superior to the other (not really, anyway). I can convince myself to go either way and I've been changing my mind on almost a daily basis for the past week. Ugh.

Talking to one attending physician who basically does what my MPH would prep me to do, he asked me, "What do you want to do?" And I said either peds or something within peds, like peds ID. And he emphatically said that I did not need an MPH to do peds or peds ID, and it wouldn't necessarily help me that much. What matters most is not how many letters I had after my name (so long as I had letters at all); what matters most is talent, hard work, and good networking. That said, if there's something I wanted to do within medicine that requires an MPH (or practically requires it), then I should definitely get it.

Anyway, what do you all think? I've talked to so many friends and several faculty, and I keep ping-ponging between the two options. I can't delay my commitment too much longer, have to make a final decision soon!