Solitude

I am a single man - an individual -
undaunted by public displays of affection,
unshaken by the pairing and coupling of others.
These symbiotic relations have made them weak,
their freedoms restrained, their hearts softened.
Who needs that?

I can, at a whim, drive to nowhere
and gaze at the light of the stars,
observing the music of the heavens.
I would take in the awe and majesty
of the universe unfurled around me,
and know the meaning of life.

I can hike into the woods
and embrace the beauty of nature -
the sound of crunching leaves, the fires of autumn,
the soundscapes of brooks and creatures.
I would be one with the breath of the trees,
and know peace and solace.

I can lay on the warm sands of the beach
and listen to the rhythms of the rolling waves.
I would dig my toes into the sand,
feel the wind and sun on my face -
close my eyes, inhale deep,
and know relaxation.

I can stay in on a cold winter day
and bake a warm pie while sipping hot tea.
I would curl under a blanket on the couch,
watching the snow falling ever so gently.
I am content and satisfied,
as this is comfort.

I run on my own schedule,
my time is mine, my thoughts and actions are mine.
I need no reminding of the pairing and coupling
that defines the life-course of others.
I am a single man - an individual -
and I with nothing more than to share it with you.

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.

Re-examine

Re-examine by ~Meow2puchiko on deviantART

On Saturday I went to a friend's wedding.  It's the 6th wedding I've been to in the last 5 years.  It was a small, intimate, outdoor wedding of family and close friends.  Though the forecast threatened scattered thunderstorms, the weather couldn't have been more perfect.

I sat (as I usually do) next to friends I knew in undergrad - some of them married, many of us single.  My friend sitting next to me remarked, "Every time I come to a wedding, I feel like I have to re-examine the course of my life."  And I sympathize with him 100%.  It seems like friend after friend has been getting married, and where am I?  Where are the rest of us?  Even if it's not entirely true, it feels as though we're lagging behind in "life progress."  It's rather unsettling at times.  I'm so far from marriage that I can't even see it in the distant horizon.

At least my other friends (married couple) spoke the truth that as we get older, our dating pool only increases (formula: minimum age of dating partner = 1/2 your age + 7).
-----
The following day I met up with another friend (also married) on my way back from the wedding.  We chatted for a while on politics and catching up and all that.  He always relished my medical stories, especially the gory ones, haha.  His wife was a trooper too with my descriptions.

After a while when it was time for me to go, he gave me the location of his brother's grave, the same brother I had considered one of my closest (and longest) friends.  It felt strange driving to his grave.  I found it rather easily.

There I stood on the road, looking between two small stone walls along rows of graves.  The sun was bright, the sky blue, and the trees and grass green.  At the far end stood a statue of Martin Luther.  And there I saw his sign, a temporary placement for his headstone not yet finished.  Standing at the foot of his grave, I could see it was a recent-ish burial as the grass had not fully grown in the spot.  I had brought no gifts, no tokens.  I saw a single black feather and placed that under the sign.

And I began to say my last words.  It was weird, talking to no one but the breeze.  I wasn't even sure of what to say, my ramblings barely coherent even to myself.  And then I teared up as I admitted that I was bi, something I never got around to telling him while he was still alive.  The words choked, stuck in my throat as I said, "I know I never told you, but I thought you should know . . . I'm bi, probably more gay than straight but I'm working on figuring it out.  I know you would've been okay with it, you would've helped me figure it out in your own way, but there's no way to know now, eh?"

It was awkward, but what does that say?  What does that mean?  That even now, even talking to no one but the air, those words would be so damn hard to say?  I suppose I really haven't changed too much since the beginning of this blog.  I don't see an endpoint.

Having too much time makes idle thoughts wander, too much time to re-examine and yet still do nothing.

Treatise on a Cultural Truth

The Truth by ~-nightm4r3- on deviantART

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

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

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

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

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

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

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

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

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

CNN: Decline in circumcisions could cost billions

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

Lifetime health care costs per man: increase by $407

Lifetime health care costs per woman: increase by $43

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

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

Lifetime prevalence of HIV for men: increase by 12.2%

Lifetime prevalence of HPV for men: increase by 29.1%

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

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

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

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

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

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

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

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

Chlamydia:

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

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

Gonorrhea:

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

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

HIV:

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

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

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

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

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

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

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

Our Bodies, Our Choice: Circumcision is Not a Joke

Why Do We Still Circumcise Boys?

Why I Didn't Circumcision My Sons

The First Lady with Grace

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

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

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

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

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.

Oddly Chaotic

M4 year has been oddly chaotic.  Where to even begin?

1.  I finished my peds sub-I last month.  The last week and a half were awesome and really renewed my desire to pursue peds.  While on night float it was just me, a senior resident, the nurses, and the attending physician that I rarely saw or talked to.  I liked the smaller team structure and I enjoyed interacting more closely with the nurses and got the opportunity to know all the patients on the service a bit better.  I also became really efficient literally overnight and that efficiency carried over when I returned to the day shift.  Unfortunately I'm still worried that my comparatively poor performance the first 3 weeks caused irreparable damage to my grade and comments, which could pose an issue later when I interview for residency programs.

2.  I'm taking USMLE Step 2 CK at the end of this month.  I'm so not ready!!  I keep hearing that most people do better on Step 2 CK than on Step 1, and I desperately hope that's true because I didn't do nearly as well on Step 1 as I had expected.  :-/  Must study study study!!!

3.  I'm working on my ERAS application to pediatric residency programs.  I'm partway through but I honestly expected to be mostly done by now.  I just haven't had the energy to dedicate sufficient time towards it.  There's so many little things to do and complete!  And I have to really do some introspection into what kinds of programs are a good fit for me.  Ugh.

4.  I have to touch base with all my writers for letters of recommendation.  In addition I need a letter from the Chair of Pediatrics.  Fortunately, in an oddly deus ex machina fashion, that bit worked out far better than I could've dreamed.  So now I'm just waiting for one letter writer to get back to me as to when he can meet with me to finalize things.

5.  I went out on a date with this guy a couple weeks back (he considered it a date, I thought we were just hanging out having brunch - clearly I suck at such things).  He's about my age, is a good conversationalist, is witty.  We've been flirting a little bit back and forth via the app we first chatted on (he has limited texts, so I avoid texting him too much).  Hopefully there may be more?

6.  Last month I visited a friend in a city about an hour west of me.  It was a lot of fun.  I also ended up (unintentionally?) jacking him off . . . while his boyfriend was out of town.  Oops.

So yeah.  Oddly chaotic beginning to what's supposed to be the best year of medical school.  But these first few months are death.