Happy New Year's Eve

Mumm Napa - Cuvee M

Happy New Year's Eve!

Best wishes for a happy and healthy new year!

PhD Comics

Wow...I'm glad someone finally modeled it. I would also multiply the numerator by "free time."

Greetings from Arcadia

Still home in Arcadia, but devoted readers of this blog (the few, the proud, the frighteningly bored...or maybe they're BOARD...haha) are probably thirsting for an update.

So far, the break has been pretty calm and unproductive...which means that all is well in the world. The new wireless network in my house has been a boon and a curse...most of my days and nights are now spent serenly sitting on the couch in my family room...reading blogs, emails, pretending to work on 3 MSP handouts due Jan 1, editing Matthew's college admissions essays, pondering that manuscript that I must write soon, and watching non-stop episodes of the CW's Supernatural on DVD. In between, I've met up with college friends, high school friends, tasted Pinkberry twice, and gone "threading" with Samantha (boy, that was funny).

A New Year's Resolution List should be due, but it might not make the deadline. It would also be interesting to do a "NOT TO DO" list, but I'm not making any promises since I still owe you a list of things that I am thankful for. I would pun on "do" and "due," but frankly you don't want to hear it.

So instead, I'm going to make of list of ways to unwrap a Christmas present, which occurred to me while watching my family on Christmas morning.

WAYS TO UNWRAP A PRESENT

1) The "Slow-Kill" -- Sliding your finger under the belly seam of the rectangular, wrapped present and cleanly tearing the scotch tape apart like a surgeon opening stitches. The name of the game is to unwrap the present without damaging the paper...usually this is because the recipient is a meticulous girl with OCD who likes shiny wrapping paper.

2) The Peeker -- Tearing open the side flap of the present (the weakest area!) to "peek" at the writing on the box before fully opening the present. This provides a sneak preview of the gift without fully denuding the present of wrapping paper.

3) The Raw Animal Attack -- Tearing open the present into long shredded strips like a crazy dog. Very therapeutic and wantonly destructive.

4) The OCD -- Using scissors to perform the "Slow-Kill."

5) The 99-Cent Special -- Using a gift bag and tissue paper a la Mom.

6) The Jeremy -- Taping together a package of gum and a dog or cat bookmark with scotch tape and a homemade "To/From" tag written with pencil on lined paper. Stuffed into the toe of a stocking. Adorable.

7) The Big Sisters -- an imaginary IOU for one Guitar Hero controller.

When People Have Questions

Not related to medical school, but this list of unanswered questions from Slate.com almost got me laughing out of my seat. Usually, Slate has a Q&A column that addresses the mysteries of nature and society...such as does the camera add 10 pounds? In this installment for the end of 2007, Slate lists all of the questions that were too random or bizarre to respond to.

Some of my favorites:

• Why are some cats softer to the touch than others? Is it possible I have the softest cat in the world?
• There was the most beautiful sunset here in Indiana last evening. Would the California fires have anything to do with that?
• Why do most reptiles go to sleep when you rub their bellies? I have done it myself with everything from domestic water dragons to wild alligators, but I heard recently that it is bad for them—and they only appear to be sleeping, when in fact they are having trouble breathing. Is this true?
• Is it "open sees me" or "open says me"?
• Is there such a thing as "crazy eyes," where the whites go all the way around the corneas and makes the person look psycho, such as those of runaway bride Jennifer Wilbanks and wife-dismemberer Stephen Grant?

Happy Holidays!

Home in Arcadia for winter break and just got back from a short trip with my family.

Lesson: The best part of getting really cold is warming up afterwards with hot chocolate!

Happy Holidays!

Uh, Good-bye, Dean Kessler?

Yesterday, I woke up at noon to find an unsual e-mail in my box. There was no subject line and it was supposedly from our Dean, Dr. David Kessler:

"Shortly after arriving at UCSF as Dean, I discovered a series of financial irregularities that predated my appointment. I reported these issues to appropriate university officials at the time, and have endeavored to work with the university ever since to solve these problems. The university characterized me as a whistleblower. During the summer, Chancellor Bishop requested my resignation. I continued to try to solve these problems. Yesterday, Chancellor Bishop terminated my appointment as Dean, effective immediately. Over the course of the past four years, it has been my pleasure and honor to work with the outstanding faculty, staff, students and donors of this remarkable school and institution. I want to thank all of you for the opportunity to foster and nurture outstanding programs on behalf of UCSF.

Sincerely,

David A. Kessler, M.D.
Professor of Pediatrics, and Epidemiology and Biostatistics"

So on Thursday night, Chancellor J. Michael Bishop dismissed Dean Kessler from his post...very abruptly and with little preparation...but the fallout from this event is going to linger.

The story has been picked up by USA Today and the SF Chronicle, and the dean's entry has already been revised in Wikipedia.

Small Step for Man

What amazes me about oncology is how science moves at a pace that is both slow and exhilarating. It seems that even the smallest steps toward improvement seem vast, and yet only highlight evermore how that elusive "cure" continually escapes us.

Of course, there are a few break-throughs in cancer therapeutics that seems awe-inspiring...whoever invented the bone marrow transplant (wow), the MOPP regimen for chemotherapy, how chemoradiation can cure Hodgkin's, how Gleevac can suppress CML. And even the "smaller" advances, like how you can harvest bone marrow stem cells from a donor's peripheral circulation using G-CSF seems so amazing and wonderful because you can spare donors a radical pelvic surgery and give patients faster engraftments (so that there are "1) shorter hospital stays 2) fewer treatment-related deaths 3) fewer infections 4) fewer transfusions and 5) lower cost"). It's when you can make advances in research that translate into enormous human benefit that makes me feel so inspired.

At the same time, there is always more work to be done. We watched a Frontline clip about a patient receiving alternative medicine for his pancreatic cancer, and it reminded me that there are still so many things to do.

Oh, and reading about bone marrow transplants have made me resolve a few things:
1) Have 3 children so that they can donate bone marrow stem cells to each other (just in case)
2) Save cord blood

Happy Birthday, Matthew!

Boston, 2005

HAPPY 18th BIRTHDAY TO MATTHEW!

Now you can vote/smoke/serve in the army/serve full jail sentences...and a few other things that I really shouldn't mention since minors might be reading this page. :)

You are the tallest/most easygoing person in our family, and I'll never forget that time when you and Samantha used the same toothbrush at home for several weeks without realizing it.

Love you always.

Gooo UCSF

Paul recently presented a Cell paper in Basic Science Journal Club about the Japanese researcher who has figured out how to reprogram regular epithelial cells into cells that closely resemble stem cells. The front page of Synapse contains an article describing the recent finding and there is a piece in the New York Times (courtesy of Iris) about how this wayward scientist found his way into research. Of note, Dr. Yamanaka maintains a lab at UCSF and we can semi-claim him as our own (besides the fact that he's a national hero in Japan, haha). One thing that interested me was why he chose UCSF:

"The best place to learn about genetics and knockout mice was the United States, where Dr. Yamanaka had no friends or contacts. He said he sent some 30 letters to American universities and specialists whose names he culled from science magazines and journals. One of the few to respond was the University of California, San Francisco, which offered him a post-doctoral position in 1993."

This is sort of an irrational thought, but thanks, UCSF, for taking a chance 14 years ago. :)

Breakable (Courtesy of Kim)

Since it's the end of Cardio for the MS1's, here is a song by Ingrid Michaelson. I am digging her mellow girly sound (and I am not usually a digger of such).

See Youtube: http://www.youtube.com/watch?v=MgZ_tu8s5Wk
See Ingrid Michaelson's site: http://www.ingridmichaelson.com/

Also highly recommend "The Way I Am" :)


"Breakable"

Have you ever thought about what protects our hearts?
Just a cage of rib bones and other various parts.
So it's fairly simple to cut right through the mess,
And to stop the muscle that makes us confess.

And we are so fragile,
And our cracking bones make noise,
And we are just,
Breakable, breakable, breakable girls and boys.

You fasten my seatbelt because it is the law.
In your two ton death trap I finally saw.
A piece of love in your face that bathed me in regret.
Then you drove me to places I'll never forget.

And we are so fragile,
And our cracking bones make noise,
And we are just,
Breakable, breakable, breakable girls and boys.

And we are so fragile,
And our cracking bones make noise,
And we are just,
Breakable, breakable, breakable girls-
Breakable, breakable, breakable girls-
Breakable, breakable, breakable girls and boys.

Thoughts Uncensored

in no particular order...

1) I am blogging right now because I can't find my syllabus. It has been missing since the midterm. This is the second time that I have misplaced a syllabus (last time was during I3). Syllabus, come back!

2) This week was killer. Today was killer.
8-12 pm - Class
12-1 pm - Synapse
1-6:30 pm - Last pediatric preceptorship
7-8 pm - MSP meeting
8-now - time-wasting (almost as bad as K+ wasting, just call me furosemide).

3) My preceptor gave me a Christmas present: a card, book, and finger puppet. I exhibit inordinate pleasure over my butterfly finger puppet. Maybe I'll bring it to lecture and wiggle it at someone.

4) The next few months are going to suck.

5) The special Tabula issue for Synapse came out today, I am so happy that the photos were printed in color!

6) Tonight, I am so proud that 13 MSP instructors came back to volunteer to teach Respiratory/Renal. The more people teaching, the less burden on everyone. Probably should have held back on teaching chronic kidney disease on Feb. 14th -- but let's be honest, my love life is on dialysis right now anyway. Besides, it reminds me of spending last Valentine's Day in the library cramming for renal...things have come full-circle.

7) I need to take a Nap-a. :)

8) The colored labels on Gmail = agonists on my beta-1 receptors => increased HR and SANS. I'm so ridiculously excited.
Colored labels > sliced bread.

Gambler's Dilemma

There's a strange paradox in leukemia/lymphoma world -- the more aggressive disease has a higher acute mortality rate, but also a greater sensitivity to chemotherapy which offers the possibility of a cure. Meanwhile, the chronic disease is more indolent (median survival is 10 years), but essentially incurable.

**This is purely a thought experiment, but in pathology lab today, the professor remarked that we are lucky that life does not force us to decide whether we (or patients) have the acute or chronic disease -- but that since survival differences between both disease eventually wash out...there is no clear answer to the question. Would you rather have a severe, sudden disease with a shorter median survival period but the possibility of salvation...or the slowly fatal chronic disease that offers you more time? A reckless gambler might bet on the first horse, the deliberate tortoise (or conservative gambler) might choose the latter.

Personally as a young, grudgingly optimistic gambler, I am more inclined to choose the more aggressive disease since it offers me a shot at being free and clear -- despite the more dismal median survival.

Paul also decided that he would rather have the acute disease, remarking, "Invariably fatal just doesn't sit well with me."

But, isn't being alive invariably fatal?

What do you think?

Talk Nerdy to Me

Watch out! Jenny and I have clinical research on the brain...it's incurable.

We've begun using nerdy jokes related to biostatistics and clinical studies, and if you imagine two Star Trek fans giggling over obscure, inside jokes about the Starship Enterprise...then you've pretty much got us pegged.

Example #1: It all started with a cup of coffee...Jenny said, "I've started drinking double shot espresso instead of single shot, and I think that it makes me more buzzed."

"How do you know?" I said, "we should do a blinded study."

"Oh, yes, we can randomize the days when I get decaf, single, or double [assuming that you can keep the volume of coffee constant]," Jenny replied.

"Yeah, and I can administer the coffee [NB: the cashier should probably decide the coffee so that I can be blinded too]. We can also see if there's a dose response!"


Example #2: Editing an article for Synapse discussing how men and women have different points of view. Jenny said, "I don't quite know how to say this, but there's a poor concordance between men and women. I mean, the R squared is not very good."

"I totally get you," I said.


Example #3: Email correspondence from Jenny:
"cirque de soleil is so cool (p<.0000001)."


Is it just me, or are these comments hilarious?

Static shock

I woke up today already a little agitated because I had forgotten to call home to wish Jeremy a happy birthday yesterday night after teaching MSP and then overslept this morning until 7:50 a.m., decided that it wasn't worth coming in 20 minutes late to lecture because it was getting almost embarassingly predictable so I slept a little more and arrived in time for the 9 a.m. lecture.

Probably a good move since my brain was more alert and I actually learned more, but one detail that the lecturer mentioned gave me a little mental static shock. He mentioned that patients with multiple myeloma do not have good prognoses and that bone marrow transplants are palliative measures designed to reduce recurrences and extend survival.

Someone whom I admire very much received a BMT for multiple myeloma -- and it almost made me cry realizing that things in life are so unfair.

Happy Birthday, Jeremy!

Midway Magic, Summer 2007

Happy 12th Birthday to my favorite tavern keeper/little camper/trumpet player/Highlander! You make life wonderful. Love you always.

Just Wanted to Drop a Line

Wow, we are rushing headlong into December and to the beginning of 2008. I didn't even make my thanksgiving list this year...next thing you know it will be time for new year's resolutions.

Promise to write more thoughtful entries, but time has been in short supply lately.

If last week had had a theme, it would have been "singing and dancing."
- Saw the musical "Jersey Boys" on Wednesday night with friends from medical school -- learned a lot about the Four Seasons and Frankie Valli (Frankie who?). Professional singers and cancers (whoops, "dancers") are AMAZING.
- On Friday evening, saw 20 minutes of an acapella concert, the UCSF Vocal Chords (semi-professional singers), and then
-Went to Japantown for karaoke (amateurs singing at an AMSA conference event).
- Saturday evening saw a dance performance at CounterPulse by the Dance Monks, an interpretative dance troupe (yay for artsy fartsy cancers!).
- Later that evening, went to the dance club Impala in North Beach, for an AMSA conference event (good natured sketchy cancers).

Ahhh, why is there so much to do?

I Heart Kids

The third pediatric preceptor session took place this afternoon, and even though the community clinic is located in Oakland and I have to take the Muni, Bart, and bus to get there...I actually don't mind that much because 1) I really like my preceptor 2) I really like the site and 3) 4 sessions is totally do-able. Today, we focused on developmental stages and learning how to use the Denver II charts for well-child visits, etc. What amazes me is that I didn't see a single English-speaking patient/family today! Through a combination of Spanish, Mandarin, and Cantonese (this one with an interpreter), my preceptor and I interviewed the parents of a 2 month-old, 17-month-old, 2-year-old, 6-year-old, and 3-year-old. It really is gratifying to work at a community clinic, especially with little kids!

Speaking of tweens, I learned that my PedPAL is still in the hospital after a month. She had aplastic anemia and a bone marrow transplant about 18 months ago, but she seems to be at the hospital more often lately. Since she can't go back to school or have much contact with the outside world, it feels to me like much of her life has been postponed or put on hold until she's more healthy, but as a result most of the time she seems very bored (at home and at the hospital). I'm not quite sure how to alleviate her boredom, I wonder if she's read Harry Potter yet.

Thoughts on Cancer

Cancer has always fascinated me on both a scientific and non-scientific level. As a deranged cellular process, the disease reveals an intricate system of checks and balances and underscores how little we actually know about the maddeningly complex “cross-talk” that Bruce Alberts compared to cell “thinking.”

Until last year, I considered cancer to be an isolated biological process. It was easy to see how the cell cycle can be sabotaged, how certain checkpoints can be bypassed and normal cellular proliferation permitted to run amok. In my head, there was a solid cadre of proteins automatically associated with cancer…p53, Bcl-2, Rb.

However, a syllabus chapter on neoplasms last year changed my view of cancer cells by pulling together information in a suggestive fashion. In normal tissue like the gut or skin, we have stem cells that continually divide into daughter stem cells and cells destined to terminally differentiate and die. Only these stem cells enjoy limitless replicative potential, and differentiation means that the cell has a one-way ticket to dying without any heirs. The syllabus also talked about how cancers can be pathologically graded based on differentiation, and that less differentiated cancers are fiercer adversaries – as though the degree to which a cell has regressed back from its terminally differentiated state reflects how feral and uncontrollable the cell has become.

And then I wondered if cancer cells had achieved the impossible…did they manage to somehow reverse the laws of nature and learn how to de-differentiate in a misguided bid for “stem cell-hood” and immortality?

In another tangent, I had never been interested in the links between inflammation and cancer until an analysis from a pilot project at Stanford showed that the only proteins associated with survival were two cytokines, IL-1 and IL-7. Suddenly, I was interested in how inflammation can affect cancer survival. The connection had never been vitally interesting before, even though it was also mentioned in the syllabus in passing. Another event that sparked my interest in the connection between immunity and cancer was writing about an ongoing UCSF brain tumor vaccine trial for Synapse, which described harvesting the tumor cells and cultivating protein complexes to boost immune response to the tumor. Although it still seems unclear to me how the whole immune system vs. cancer situation exactly works, I really like the connections.

No one else will agree with me, but the most outstanding lectures in Cancer block so far were given by Dr. Doug Hanahan on the topics of angiogenesis and metastasis. For some reason, his lectures really seemed to address where my thoughts on cancer biology have been turning to. There was an interesting mention of an “angiogenic switch” and the idea that there are “bad” inflammatory cells, fibroblasts, etc. that somehow aid cancer cells. In the metastasis lecture, I was intrigued by the notion that metastasis resembles a “re-awakening” of the far-flung migratory habits of cells during embryonic development. Re-reading Hanahan’s syllabus chapters made me intellectually excited. In the end, these two processes – angiogenesis and metastasis – are two of the keys to fully understanding cancer and how to cure it.

Busy Busy

The last week has been hectic:

Nov. 16 - gave a presentation on summer research for a shot at the Dean's Prize
Nov. 16 - flew to JFK and hurried to New Haven, CT for the Harvard-Yale game
Nov. 19 - spent 12 hours getting back from Yale to San Francisco
Nov. 20 - studied and took a Cancer midterm (plain crazy), then stayed up until 3:30 am finishing the last problem set for Biostatistics 183 (an imaginary grad course that I am auditing for no reason, sheer insanity). Found out that my project won the Dean's Prize! (there were 4 recipients this year!)
Nov. 21 - flew home to LA in the early morn
Nov. 21-24 - saw family, ate lots of food, shopped

Harvard-Yale 07

Yale Med Tailgate
Blockies!
"Rushing" the field after a 37-6 victory over Yale

Thanks for a fabulous weekend, Kim!

Class Play Videos

For your viewing pleasure...http://www.youtube.com/user/ucsf2010

Let the Trash Talk Begin

Harvard-Yale 2005

So...it seems strange that even when you leave Harvard...you can't really leave it behind. :)

No matter how much I might roll my eyes or moan and groan about undergrad, it's important to point out that my spine stiffens a little when a med classmate mentions Harvard basketball's recent...how do i put this delicately...total spanking at the hands of Stanford (111-56) last friday. Even being generously endowed can't seem to help Harvard basketball players. But at least we're well-endowed.

Anyway, I only mention this because I am flying into New Haven this Friday evening for a blockmate reunion at the Harvard-Yale football game (better known as the Game, which is sort of pretentious for two really mediocre football teams duking it out in subzero weather while everyone else is tailgating). Harvard-Yale is only marginally about football and bragging rights to the victor...it's more like Woodstock for the Ivy League...a reason to reunite with friends, drink beer, and take part in a time-honored ritual of pretentious aping and snooty trash talk against the Pepsi of the Ivy League...that annoying younger school, Yale. Boy, I wouldn't miss it for the world.

Here is an Op/Ed from today's Harvard Crimson, not sure that it's entirely correct:

The Real Difference
All universities are equal, but some are more equal than others

Published On Tuesday, November 13, 2007 12:50 AM
By ALEXANDRA A. PETRI
Contributing Writer

Every November, Harvard and Yale attempt to set up the impending Game as an epic battle of Good vs. Evil, Luke Skywalker vs. Darth Vader, or Plucky Underdogs vs. Bulldogs. But every year the actual struggle seems more like Hatfield vs. McCoy, Montague vs. Capulet, or Luke vs. That Masked Vader-Like Figure in Empire Strikes Back That Actually Turns Out to Be Luke’s Psyche (Or Something). Are we just fighting ourselves? Or is this indeed an epic smackdown between the representatives of two vitally different ideals?

Even those who liken Harvard and Yale to twins have to admit that no twins are truly identical. For instance, some twins have different genders or different personalities. Other twins are separated at birth and then reunited in Shakespearean comedies. So, what makes John Harvard different from Eli Yale? Personality? Gender? Or something else altogether, like Eli’s birth defect?

According to Facebook’s Network Top Ten statistics, there are some subtle but meaningful distinctions between the average Harvardian and the average Yalie. On a typical day, Joe “Eli” Yale relaxes to the music of his favorite artists, U2 (Yale’s #1, Harvard’s #2), The Beatles (#3 and #5, respectively), and, of course, Beethoven (Yale’s #7; not on Harvard’s list). He engages in his favorite activities—reading, politics, and music, in that order—as well as some other treasured pastimes—perhaps a little cooking (#7), history (#9) or philosophy (#8). Clearly, he is in no way a pretentious asshole. And just to drive this point home, he pops in his favorite DVD, “Amelie.” (Yale’s #1, Harvard’s #6). He flips listlessly through his favorite book— “Harry Potter,” also Harvard’s #1—and his second-favorite book, “Pride and Prejudice” (Harvard’s #4), and thinks about how much he enjoyed reading “Lolita,” “Crime and Punishment,” and “Lord of the Rings” (none of which made Harvard’s list). He is 20 percent liberal, three percent conservative, and 17 percent of him is in a relationship, a statistic that has been hard to explain to the other person involved. He goes to his computer, where he has been actively following Yale’s top news story of an “Eight-Limbed Toddler Believed to Be Vishnu Reincarnation.”

Meanwhile, John Harvard flips on some Coldplay (#1 Harvard, #5 Yale) and sets about his favorite activity: Music. His room is decorated with posters of his favorite bands: Pink Floyd, The Red Hot Chili Peppers, and The Killers (none of whom make Eli’s top 10; he’s too busy listening to Beethoven), and favorite movies: “Little Miss Sunshine” (#1, Yale’s #5) and “Fight Club” (#2). Admittedly, he and Eli have similar taste in movies—six of the ten titles are the same. But unlike Eli, he enjoyed “Love Actually” and “The Shawshank Redemption,” and felt that “Crash” was edifying, but also thought-provoking. That’s how John likes his movies.

He is not a pretentious asshole either—as some of his favorite books attest: “1984,” “The Great Gatsby,” “Pride and Prejudice,” “To Kill a Mockingbird,” and “The Catcher in the Rye.” John just loved that AP English reading. Every single one of those books changed his life, as he wrote in his college essay. Some of them changed it multiple times. In his spare time, he reads modern classics with long, paradoxical titles like “The Unbearable Lightness of Being.” Also the Bible, although not quite as often as Eli does. He enjoys dancing, photography, and art. He is 17 percent liberal, three percent conservative, and 15 percent in a relationship. Another 15 percent of him is single. As they say, it’s complicated (one percent).

Yet all these comparisons hint at a more fundamental divergence. Yale students want you to know that they enjoy Beethoven. Harvard students want you to know that they enjoy Snow Patrol. Yale students sure love their long important novels by Dostoevsky, Nabokov, or Tolkien. Harvard students sure love their interesting modern novels by people with names like Milan Kundera and Jhumpa Lahiri. Yalies enjoy history and philosophy and put Tolkien books and movies on their profiles. Harvardians enjoy Dancing, Art, and Oscar-winning movies about race. Yale students want to impress you with what they’re doing. Harvard students want to impress you with how cool they look while doing it.

Someone wise once said, “Going to Harvard means you will have to spend the rest of your life proving to people that you’re an idiot.” Yale students don’t have that advantage. That’s why they need to tell us they’ve been reading “Crime and Punishment” and watching “Amelie” again. Everyone has heard of Harvard, and this makes a wider range of people want to come. It also means that your average Harvard student is more—dare I say?—normal than your average Yalie. Harvard’s sheer world fame draws excellent students from all countries and backgrounds while Yale, less-known, still feeds off more exclusive, east-coast-preppy sources. 46 percent of Yale’s freshman class came from private and parochial schools. Only 36 percent of Harvard’s did.

Some people say that by putting an end to early action, Harvard will open floodgates to people who are applying on a whim “because it’s Harvard.” But when these people get in—as they frequently do—it is because they deserve to do so. Everyone praises Harvard “for the students.” But what makes Harvard’s students so great is that they are in many ways a cross-section of the larger world. They are normal people who happen to be excellent, and this sets them apart. People who go to Yale go because they want to attend Yale. People who go to Harvard go because they can.

Alexandra A. Petri ’10 lives in Eliot House. Her column appears on alternate Tuesdays.

We Shall OverCome

Ovarian Cancer Support Bands

(youth sizes "for the petite ladies")

Last Friday, a classmate named Mike Frederick presented the best damn Clinical Sciences Journal Club in recent memory. It was a paper demonstrating the effectiveness of oophorectomies (surgical removal of ovaries) as prophylaxis against ovarian cancer in patients with BRCA1 and/or BRCA2 mutations.

The strength of Mike's presentation rested upon his courage to discuss how ovarian cancer has affected his life. He began the presentation with the sound a woman singing opera -- the voice belonged to be his sister, who passed away from ovarian cancer the summer before Mike started medical school at UCSF. Mike wove his own family history and his personal experiences together in a way that amused, touched, and educated the audience (a crowd of MS1's and MS2's, journal club has always been a proudly student-run affair). My eyes were constantly tearing up, and it was so memorable watching Mike onstage showing us videos of his family and photos of his sister...in between Kaplan-Meier curves and data tables of the patient population in the study.

What will really stay in memory is how the presentation was so quintessentially "Mike" -- a guy who is proud of his family, a down-to-earth, unapologetically opinionated farm boy from Nipomo, CA, who can bake banana cream pies from scratch and tell you the difference between a starfish and a sea star while he skin dives for abalone. A guy who formerly boasted tonsils the size of testicles (before he had them removed last year) and who has helped to make UCSF medical school an amazing place to be.

Busy Thursday

Today we had a Small Group from 8-10 am on molecular methods for detecting genetic mutations, focusing on Southern blotting and microarrays.

From 10-12 pm we had a lecture on cancer screening procedures for cervical cancer, colon cancer, breast cancer, and prostate cancer. It was interesting learning about the pros and cons of each screening test, and how there is a constant balance being weighing harms and benefits.

The Synapse lunch meeting from 12-1 pm featured a columnist from the San Francisco Chronicle, CW Nevius, who has been creating ripples in the community through his writing on the homeless in San Francisco.

Traveled from 1-2:15 pm to Oakland for my pediatric preceptorship. I really enjoy working in a community-based clinic with my preceptor, who is an Asian woman who speaks fluent Spanish. Not sure if this was intentional, but UCSF has arranged it so that I have been able to visit many different types of practices during my short time here...and each is different from the comfy, wonderful privileged academic medical centers where I have worked in the past! My first preceptor was a medical oncologist at Kaiser SF (HMO system); my second preceptor was a Cantonese doctor who divided his time between oncology and primary care in his private practice in Chinatown, and my current preceptor works in a community-based clinic as a pediatrician for the Cantonese/Hispanic community. Today, I got to practice my rusty Spanish skills by taking a short medical history and converse in Mandarin and listen to Cantonese. Undoubtedly, pediatrics has the cutest, most charming patient population. You can't help but smile when you see them.

The Ella Song

For the Class Play...

Shigella (from Rihanna’s “Umbrella”)

From the new album, “Good Tuna Gone Bad”

Voiceover: “It’s Shigella, bitch.”
OR: yeah, shigella, good tuna gone bad. Take 3. Action:

Got ‘crobes in your blood
Let them come, bacterial load on the rise
Comin’ up with a surprise
When infection comes we thrive, we all the “ellas”
You stay under the weather
And you never get better, you know ‘em
In anticipation, get a vaccinationfor inoculation. Stacked shots for the a sicker day.
D-LO, Brain Man is back with a gram stain
Ellas where you at?

(April - Rubella)
We have the shots
Give them 6 months apart
You know you need vaccines
And they won’t leave a scar
Baby cause in the dark
You can feel infection start
That's when you need me there
Cuz kids will always share
Because

[Chorus]
(Susan – Legionella)
When the drops spray, we’re there together
In your lungs I’ll be forever
Legionnaire is my name
Grow me up (and) see me with a silver stain
Now that you’re coughin’ more than ever
Know that we'll still have each other
You can call me Legionella
You can call me Legionella
(Ella ella eh eh eh)
Measles Mumps and Rubella
(Ella ella eh eh eh)
Call me Varicella
(Ella ella eh eh eh)
Salmonella and shigella
(Ella ella eh eh eh eh eh eh)

(Bianca – Varicella)
These vaccines, will never come in between
You’re part of my entity, here for Infinity
Just when the itching starts
That’s when the friends depart
If you don’t like someone,
You should just have some fun
Because

[Chorus]
(Melissa - Salmonella)
When you eat those eggs, we’re there together.
On the john you’ll be forever
Blame the fecal-oral spread
Don’t get scared when your stool turns wet and red
Now that you’re crapping more than ever
Know that we'll still have each other
My name is Salmonella
My name is Salmonella
(Ella ella eh eh eh)
Measles Mumps and Rubella
(Ella ella eh eh eh)
Call me Varicella
(Ella ella eh eh eh)
Legionella and shigella
(Ella ella eh eh eh eh eh eh)

(Climax)
Now you’ve met four of the five
Meet the Queen Bee of the hive
Give in to me
Ten of me…is all you need…to bleed
So go on and let the feces pour
I'll be all you need and more
Because

(Elaine – Shigella)
With your hands unwashed, we’re there together.
Diarrhea’s not forever
Shiga toxin – what a pain
After me, you’re never gonna be the same
Now that you’re crying cramping more than ever
Know that we'll still have each other
You can’t stand – no one fights Shigella
You can’t stand – no one fights Shigella
(Ella ella eh eh eh)
Measles Mumps and Rubella
(Ella ella eh eh eh)
Call me Varicella
(Ella ella eh eh eh)
Legionella and salmonella
(Ella ella eh eh eh eh eh eh)

[close up shot of clean toilet bowl flushing]
It's draining
Ooh baby it's draining
Baby give into me
Give into me
It's draining
Oh baby it's draining

Class Play

Just got back from the Class Play...it was AWESOME.

So proud of UCSF Class of 2010 and the amazing talent, dedication, and energy. :)

My favorite skit remains the Office Parody, the Small Group. The pacing, the filming, the acting, the dialogue was so accurate and clever.

:)

Celebrity Look-Alikes

Above: Dr. Joe Derisi, Boy Genius

Doogie Howser, actor

L: Dr. Anthony DeFranco, course director for I3 (fall 2007)


R: Woody Allen, actor


Some Hollywood celebrities bear a striking resemblance to the academic superstars at UCSF.


This morning we had an awesome lecture on DNA microarrays from Dr. Joe Derisi, a 2004 recipient of the MacArthur grant. His other claim to fame is that he is the spitting image of Doogie Howser, boy genius!

Thanksgiving Should Be Everyday

Feeling blue today, but I found this email that I wrote to myself on 11/27/06 with the subject line, "Thanksgiving Should Be Everyday." It's actually an insightful time capsule into my life at that moment approximately one year ago.

"Thank you, God, for...
1) the health of my family, my friends, and myself this past year
2) nudging me to go to UCSF and to meet so many wonderful people
3) your grace and forgiveness
4) the wonder of taste -- from a 2004 Mondavi muscat to foie gras to hot salty french fries with ketchup -- which reminds me that I am alive and here on this earth for a short time
5) Jey
6) the sensation of falling in love
7) beauty in all things -- even the beauty of pain
8) knowing that ignorance is not bliss...it's the imperfections that make life worth living
9) allowing me to pass my cardiovascular exam
10) the respite of sleep
11) the warmth of love
12) letting me pretend that I'm Christopher Smart, but without the cat Geoffrey
13) my adorable brothers and sisters and wonderful family
14) my amazing friends who always give me an ear or a bed to sleep in
15) the 2004 Mondavi muscat
16) the opportunities that have been available to me since birth
17) giving me the chance to grow and develop emotionally
18) giving me an elevator to commute to school
19) my imperfect, humble, passionate, little soul."

Mailboxes

Don't want to sound alarmist, but I am annoyed that someone is stealing objects from the student mailboxes in the medical student lounge!

The Heroine on Heroin

From the SF Chronicle last year...

A homeless beauty and the beast, heroin
A slave to her addiction, young woman squanders her family and her potential
Kevin Fagan, Chronicle Staff Writer
Saturday, March 25, 2006

Rhonda Bye had a lot going for her -- brains, beauty, feisty strength.

Heroin and crack crushed it all.

The narcotics ruined her looks and attention span, snuffing out her potential both as a young clothing model for Nordstrom and as a computer whiz who could fix office network problems. Three years ago, a slave to her heroin addiction, Bye landed on San Francisco's streets as a homeless panhandler.

Still, she refused to give up, fighting her way through a frustrating maze of city social services to get into housing and drug rehabilitation. She shook off her addiction, and in the last couple months she had been talking about retraining to work with computers again.

But it was too late. Drug abuse and the ravages of street life had damaged her kidneys so badly that, in mid-February, doctors told her she would need dialysis for the rest of her life.
She missed her treatments three times in a row and went into a coma three weeks ago.

On Wednesday, she died. She was 39.

Bye leaves behind two sons and a daughter -- and a lifetime that her family hopes will be an example, in the harshest way possible, of how drugs and homelessness can destroy a person.

"She is an Exhibit A on what heroin and crack does to someone who is unbelievably beautiful, has the sweetest personality in the world, and is even smart," said Bye's brother, Robert Davis of Everett, Wash. "She could have done so much in life, so much. But drugs. ... It was drugs."
Bye lies in the San Francisco General Hospital morgue, the destination of all such indigents who die alone in the city from the ravages of drug abuse. But members of her family, many of whom haven't seen her in years, aren't focusing on that image. They choose to remember her in the days before everything went bad.

"She had such a great smile, back when she had teeth, and such a cute giggle," said her mother-in-law, Kay Vestre of Kent, Wash., who is raising Bye's three children and is a manager for the local child protective services office. "Back before she did drugs, they hired her at my workplace to work on the computer system, and oh, my, was she good. She became a trainer for other technicians."

But that -- like most of the promising things in Bye's life -- was before heroin seized her.
Bye was raised in Washington state, by a single mother who struggled on welfare or low-paying jobs for much of her childhood, her brother said, "but she always had the strength and brains to try to make something of herself."

Throughout middle school, she attended Bellevue Modeling Academy and walked the runway showing off clothes for Nordstrom. She pulled A's and B's in school, he said, "and by high school she was probably the most popular, cutest girl in class."

Then she met David Bye, whom as recently as this winter she called "the love of my life and the most interesting guy I ever met." By 17, she had dropped out of high school, and they were married, their first child on the way.

"The two of them just started doing cocaine a bit, and very slowly over the next bunch of years they lost what they had," Davis said. Jobs came and went, but about six years ago heroin had gripped them both, and they wound up on and off the streets. Vestre got custody of their three children -- and three years ago, things exploded out of control.

David Bye shot a man to death in Seattle in a fight over insurance money, and the couple fled toward Mexico. San Francisco police found them huddled in an alleyway, arrested David Bye and extradited him to Washington. His wife was left on the street -- and there she stayed.
Over the next year, she became a fixture at the Duboce Street off-ramp from Highway 101, the smiling, gentle woman with the ever-ready sign pleading for "just a little help." With her husband out of the picture for the first time since she was 17 -- he was convicted last year of second-degree murder and is serving 32 years in prison -- she was truly on her own for the first time in her life.

"This is not how I wanted to end up," she said one rainy day in 2004 as she begged in traffic. "I want to set a better example for my kids. All I need is a little more of a chance."

That chance came that year, when city Human Services Director Trent Rhorer struck up a conversation with her as she visited with a Chronicle reporter and photographer. He summoned an outreach worker, who signed her up for housing and rehab appointments.

It proved to be the one spark she needed. Bye followed up her many appointments diligently, and nearly three months later, she had a room in the Elm residential hotel and was firmly on methadone treatment to kick heroin.

"Rhonda struck me as someone who genuinely recognized her plight and really wanted to live a better life," Rhorer said. "She was no dummy. But sometimes the toll of drugs is just too much, and it catches up with you.

"What this tells me is that we have to work even harder to get the chronically homeless inside before this kind of damage sets in so deeply."

Her family hoped that she would learn so much from her street ordeals that she could become a counselor someday. Bye herself held that ambition.

"I know how the whole thing works now," she said one day last month in her hotel room, going over brochures of computer training classes. "Man, I could actually help people avoid the crap I've had to live through. Wouldn't that just be great?"

E-mail Kevin Fagan at kfagan@sfchronicle.com.

iClicker

iClicker

Dr. Bruce Alberts (science god, author of The Cell, ex-prez of the National Academy of Sciences, and UCSF faculty member) gave us a series of lecture on cancer biology this week. He was a fairly good speaker, and he introduced a new teaching device called the iClicker. It's a battery-powered remote control that allows people in the lecture to press ABCDE multiple choice answers and interact with the lecturer's pre-made multiple choice questions.

I think Harvard had a version of this in some science classes, but I've never used it before. At first, I viewed the iClicker as a tool of oppression... I felt like it was cheesy and coercive and not very instructive since multiple choice questions are generally reductionistic. However, I give kudos to Dr. Alberts for trying a new teaching tool and some of his questions were pretty interesting and challenging.

Britney Spears?

Despite reports that Amy Winehouse would be the most popular costume this year, no one knew what my costume was. As a side note, I thought of this costume idea on Sept 6th (see post)...way before Perez Hilton, et. al.! (sorry, must point that out).

Since I had a microphone, here are some guesses made by people at UCSF:

- Ashlee Simpson
- Sarah Silverman
- Christina Aguilera
- (Rehab!) Britney Spears
- Japanese pop princess
- random Halloween punkette

It's okay, it was fun dressing up!

Home for Halloween?

The Castro from the NYT

Tomorrow is Halloween, but we have no place to celebrate! Historically, the Castro has been the setting of a flamboyant Halloween party for San Francisco, but has been troubled by excessive drunkenness and violence in recent years. The city responded by trying to prohibit alcohol and strengthen security. Last year, 9 people were wounded in a shooting at the Castro and the city finally threw in the towel and canceled the party:

"The city is shutting down public transportation to the Castro on Halloween and has begun a Web site, homeforhalloween.com, that lists “fun” alternatives, including a Halloween blood drive and a “Monster Bash” — in San Mateo." (great article in NYT)

Oops, have to go to class now. More musings later?

Drunken Pumpkin

No, it's not a spider. It's your brain on GIARDIA! (photo by Irene)

Drunken pumpkin carved by a creative MS1. (photo by Irene)

Outstanding pumpkin by Paul...it's PUMPKIN PI! (photo by Paul)

Yay for pumpkin carving parties, pumpkin pie, and hot apple cider (didn't drink any...)! Some other awesome pumpkin designs: sand dollar, Bosox commemorative, cat on a moon, Michigan.

Rule of Thumb

O'Brien S et al. N Engl J Med 2003;348:994-1004

Loosely paraphrased from Dr. Andrew Ko's lecture:

"A lot of times you might wonder what makes a clinical study significant or useful. There are a lot of ways to determine this, but a mentor of mine during my oncology fellowship at Stanford gave me this rule of thumb: if a person sitting in the back of the room can measure out the space of his or her thumb between the two survival curves on a Kaplan Meier graph, then the study is something to write home about."

Simple. Cute. Useful.

The Other 70%

Paul and I have a dream...to visit 70% of Napa Valley's wineries before graduating from medical school. Since we need 70% to pass an exam in medical school, it seemed like 70% was a good benchmark for other important life pursuits.

Before visiting any wineries, Paul has a custom of visiting the Napa Valley Visitor's Center to get a map and some recommendations. Unfortunately, we may have realized last Tuesday that we've hit the 20% mark and outgrown the wisdom that the tour guides can offer us.

The following conversation was with an elderly lady (EL) at the Napa Valley Visitor's Center:

S: "What wineries do you recommend around Castello di Amarosa?"
EL: "Well, have you been to Sterling?"
P: "Yes."
EL: [continuing] "They have a lovely aerial tram [proceeds to show us a flyer]. Some people call them gondolas..."
P: "What else would you recommend?"
EL: "Well, V. Sattui has a lovely deli, you should definitely go there."
S: "We've been there."
EL: "Have you been to Beringer?"
P and S: "Yes."
EL: "Well, you can try Raymond. I have a coupon for you."
P: [Looking for recommendations on red wines/white wines/outstanding vintages] "What do they have there?"
EL: "Wine."
P: [blank face] "I see."


Notes:
Castello di Amarosa (awesome $25 castle tour and tasting)
Raymond (pretty good reds)
Grgrich Hills (so-so, tasted 95-point muscat, free glass)
St. Supery (outstanding Sauvignon Blanc, '02 Cabernet Sauvignon, definitely a sleeper hit of a winery)

Do you know a great cancer publication?

Wanted: An interesting paper for Clinical Sciences Journal Club. Please send my way!

Currently, I am home in Los Angeles enjoying the company of family and great food. On Monday, we begin Cancer block...

GU Exam

A few weeks ago, we learned how to do male and female genitourinary (GU) exams. Despite some reservations, the experience was actually extremely educational and enjoyable. The key is to have an excellent patient educator (someone who is trained to train medical students on how to do pelvic exams), who focuses on training us to become excellent clinicians. Our patient educators were relaxed, friendly, knowledgable, and patient.

Statistician, Feisty

The MS2's have a 6-day-long break after the I3 final on Monday. On Thursday, Paul and I took the biostatistics midterm...a grad school class that we are auditing for fun. It's strange to be taking a "fake" class and a "fake" test, but it's kind of funny at the same time. It's definitely something that we are doing purely for ourselves, and the idea is rather liberating.

Since the midterm was open book and open notes, I didn't even motivate myself to study. Instead, I stuck post-it notes inside the textbook for the formulas.

During the exam, I found the following item under the textbook index:

"Statistician, feisty."

I love how Glantz managed to stick that into his sixth edition textbook.

How can I NOT take his class??

Deadly Amoeba

This is your brain on amoeba

Case: A 30-year-old Danish tourist (blond, athletic, good-looking) takes a tour of the Southwestern US on the "Green Turtle" (a school bus painted green and modified by hippies in the Haight to tour around the U.S.). The tourist took a swim in the hot springs in Arizona, but a few days later presented in the ER at UCSF with a headache, nausea, vomiting, and neck stiffness.

Was this a case of meningitis? The spinal tap revealed no bacteria. A few days later, the attractive Danish tourist died and his autopsy revealed the brain pictured above. The huge dark sections are portions where a deadly amoeba has penetrated his brain.

Naegleria fowleri is a free-living amoeba that lives in warm water. They are known to venture up a swimmer's nose, penetrate the cribiform plate, and reproduce in the brain, inevitably causing death within a few days. The mortality rate is 95% within one week.

I can't imagine being an infectious disease expert...how can you avoid becoming paranoid?

The Blind Man's Dilemma

Writing this right now is utter insanity because I have not started reading the syllabus yet and it's Friday night before a Monday exam. However, I wanted to write this down before it becomes forgotten.

The aged Chinese man sitting in the closet-sized exam room was looking at an obscure point in space about 1 foot away from my head. He was a friendly grandfatherly character, with black plastic glasses, eyes clouded by cataracts, and a distinct scholarly air perhaps manifested by his fastidiously pressed striped shirt, bright red suspenders, and black trousers. Around his shoulder was a green cloth bag.

The CT scan had shown cancer in his prostate, bladder, and in the right pelvic region and his kidneys were backed up with fluid -- but he knew that his case was difficult. As the doctor began describing how he must begin chemotherapy within a week as a palliative measure to shrink his large prostate cancer and permit him to urinate again (a quality of life issue), the blind man interrupted the scheduling by saying, "Wait, not before my birthday party! It's on the 28th."

The oncologist reminded the blind man that the tumor would only grow larger if they waited 2 weeks, but the blind man remained adamant.

"Can you guarantee that I won't feel nauseated and half-dead from the chemo?" he asked.

"No, of course not," said the honest doctor.

"Well, now that's a problem. I want to feel good during my 82nd birthday party."

"It's up to you," said the doctor, "The chemo is not going to cure you, but the tumor is just going to grow bigger."

The blind man seemed to relax after he heard the words "not going to cure you."

During the physical exam, the blind man lay down on the bench without removing his green cloth bag. It was a curious omission, but it became clear after the doctor lifted the patient's shirt and pointed out how there was a tube emerging from the blind man's back, wrapping around the front and ingeniously hidden by a seam in the black trousers (mended by his wife). The tube emerged from the trousers and dove into the green cloth bag (created by his wife's female friend). Since the blind man could not urinate with the prostate cancer blocking the ureters, there was a tube implanted to drain the kidney, allowing the urine to emerge from a plastic pipe and draining into a plastic bag hidden by the innocuous green cloth. In my mind, the man was carrying an external "pee-bag" around.

Talking to the blind man, it was clear that he was well-educated and that he knew that his case was (in his words) "terminal." He looked forward to gathering his friends and family for his birthday, and he seemed so spirited, saddened, and strong. He proudly said that he would like to finish a manuscript before he dies, apparently he was a scholar in Asian-American studies, and I knew that he still looked forward to the future and had goals.

Somehow, when I am talking to elderly cancer patients, I feel like they have reached the delicate balance of acceptance and hope that continually escapes me.

Erasing Memories

No comments for now, but a very potent and vivid piece from CNN.com...

"She was worried about the lump and worried about the children who were worrying about her. She was, however, most worried about the anesthesia. "What if I don't wake up?" just wasn't a question I could answer sufficiently for her. Some people take no solace in statistics (that, for example, there are two or three deaths per 1 million patients anesthetized) — these patients are the medical cousins of the folks still crossing the country by train or bus rather than "risking the airplane." So I warned her that there might be a little pain and agreed to do her biopsy under a local anesthetic — but only if she would allow an anesthesiologist in the room, just in case.

The lump was growing near — maybe on — the inner end of Ellen's collarbone, meaning that during the biopsy I might have to use a tool that goes "crunch." It's pretty hard to numb up bone with a local anesthetic so I was glad to have Frank, the anesthesiologist, there at the head of the table with some IV sedatives, in case Ellen got panicky or was in too much pain. She was adamant about not going under, but agreed to "some sedation" if we thought it was necessary.
I can understand not wanting to lose consciousness. It's arguably the most precious thing we have. And although serious complications from anesthesia are truly rare these days, so are bone tumors — and she clearly had one of those. Ellen had a history of cancer too — it had not been a cancer that was likely to spread to the bone and there hadn't been any sign of it for years, but it had been a malignancy. This lump was growing at the end of the clavicle, in the place where arthritis often produces a lumpy enlargement. But Ellen's lump had come on too fast; it felt fleshy and, most significantly, unlike arthritis, it wasn't tender at all. As hard as I pressed on the lump that day in the office, it didn't hurt. That's why I booked the biopsy.

I've been in many operating rooms over the years, with the highest-tech, ultra high-quality equipment around, but I don't think I've been in one where the intercom, a low tech app if there ever was one, really worked. And we found that was true in our room that day.
Ellen's procedure got off to a fine start. She was O.K. with the needle-sticks for the lidocaine and she stayed calm and collected under the layers of paper and plastic that we used to drape off the surgical site. When I got in there, I saw that the lump was growing from the bone. I warned her it might hurt but she didn't make a peep when I used the tool that crunches and bit off a piece of bone for the pathologist.

I ordered up a touch prep — a quick microscopic look at the cells of the specimen. We would know in 15 minutes if there were cancer in the lump. While the specimen was in the pathology lab, we washed out the wound and started to sew it back up, layer by layer. The inch-long incision was on a very conspicuous part of this youngish woman's body, right where a necklace or the neckline of a fancy dress might lead the eye. I sutured slowly. We were still waiting for the pathology report anyway. It was quiet in the room. I made small talk with Ellen and the nurses. Ellen was O.K. but nervous. She talked about her kids, about how much driving she did everyday shuttling them around. The topic of the tumor, and what it had looked like, was given wide berth by all of us. I finished stitching, but I had to stay scrubbed — we couldn't take off the drapes until pathology told us they had a sufficient specimen. There wasn't much else to discuss; it was real quiet and, rare for the OR, a little bit awkward.

"Dr. Haig?" A voice over the intercom, harsh and loud.

"Yes," I said. "Is this path lab?"

"Yes, can I put on Dr. Morales?" the voice replied, referring to the pathologist looking at the microscope slides of Ellen's specimen.

"Have him call in on the phone," I said. The drill, which everyone knew, was that the circulating nurse would hold the phone to my ear while the pathologist told me what he saw.

But instead of an "O.K." there was silence, and then, "Scott, this is Jorge, can you hear me?"

"Yes, but hold on, we're under local in here," I said. "You'd better call the desk and have them put you through to the phone in the room."

"Scott, I can barely hear you but, listen, this is a wildly pleomorphic tumor, very anaplastic. I can't tell..."

"Hold on, Jorge — let me use the..." But he couldn't hear me and kept on talking.

"...what the cell type is, but it's a really, really, bad..."

The circulator was moving toward the intercom on the wall, but she wasn't going to make it.

"...cancer."

Ellen's shuddering gasp, then shrieks came from under the drapes: "Oh, my God. Oh, my God.
My kids. Oh, my... my arm..."

The burning pain in Ellen's arm was due to the rapid application of propofol, a paper-white liquid medication, which the perceptive Dr. Frank had plugged into Ellen's IV the second he heard the c-word. When he saw her reaction, he pushed. The drug, sometimes called "milk of amnesia," stings some patients sharply in the veins, but what it also does is erase your last few minutes. (Think of the "neuralyzer" from the Men in Black movies.) Oh, and it puts you to sleep. An amazing molecule, a great anesthesiologist and a great save.

Not everyone agreed. I looked up at three sets of eyes, the nurses' eyes, that bored into Frank and me accusingly. How can you do that? they demanded to know. Don't you need consent or at least fill out some kind of form before you steal a patient's last 10 minutes? But all I could say was, "Awesome job, Frank." Somehow with that, and with the calm sleep on their patient's face, we were given not forgiveness, but a reprieve.

Ten minutes later Ellen woke up, happy and even-keeled, not even knowing she'd been asleep. From the recovery room she was home in time for dinner. "The procedure went smoothly, but we'll have to wait for the final pathology reports," I said, which was not exactly the whole truth, but it let me get the oncology people cued up, a proper diagnosis, and Ellen herself emotionally prepared. I would give her the bad news at a more appropriate time.

The ending was not quite happy; it was a recurrence of the cancer she'd had years before — fairly rare for that type of tumor. Ellen died of it about six years later. I confess I never told her about the incident with the intercom.

Over a decade later, I'm still not sure that was right.

Questions of withholding bad news, wiping out bad memories — plastering over wayward cracks in our minds with chemicals — are answered thousands of times everyday, without ever being asked. Ethics committees and experts exist in our hospitals, but what they have to say counts precious little down in the trenches, where intercoms fail and human minds treat human minds, in real time. You would think, by now, that the distinction between treatments using words (or ideas) and chemicals (or electric currents) is starting to blur. (If an hour of psychotherapy accomplishes the same thing as 20 mg of Prozac — that is, a boost in mood and serotonin levels — is there a difference?) But it is not. Everyone I know who deals with medicines that affect minds seems to operate with a very clear functional distinction between personhood — the realm of virtue, vice, responsibility and creativity — and brain chemistry. That distinction was clear in the eyes of my nurses that day. Something more important than a chemical balance in Ellen's brain had been violated — only a little and, obviously, with benevolent intent. But it hadn't been as simple as pushing a rewind button. Something there had borne the unmistakable quality of wrong.

As mundane, as miserably human as a soccer mom "dying young" of cancer might be, I found such value and such meaning in the way Ellen clung to her consciousness, the personhood she needed to care for her family. Much of what we read about brain science in the media today would have us believe that we're nothing more, really, than very fancy machines. And surely what we're learning about the physical brain is exciting and powerful — but thinking honestly, it remains so limited. We can trace the brain pathway of a drug "high," we can call it pleasure, but that tells us nothing about what so many people choose instead — deeper things that somehow beat out mere pleasure as the reasons for doing what we do. Those comforts — of ultimate meaning, virtue, peace and joy — have little to do with molecules."

Dr. Scott Haig is an Assistant Clinical Professor of Orthopedic Surgery at Columbia University College of Physicians and Surgeons. He has a private practice in the New York City area.

Cancer and Health Disparities

Yesterday, I attended a lunch elective on African American Health Disparities. It was a talk given by Dr. Mack Roach, the chair of Rad Onc at UCSF, who strongly believes that research focuses too much on attributing biological/genetic differences between races to cancer outcomes. It was a fascinating talk filled with numerous study results and I realized a few things:

1) It's almost impossible to separate which cancer outcomes are biologic and which are psychosocial given the limits of our current studies.

2) Dr. Roach is correct in that there is an inherent bias for positive studies and this impedes funding/publishing, etc. His work showing that racial differences do NOT affect outcomes has been hard to publish for this reason. It makes me glad that we have someone at UCSF pushing for this counterview.

3) I get really excited seeing a powerpoint with lots of data from cancer studies

4) Is my fate as an oncologist sealed?

Excuse Me, Chancellor Bishop?

Chancellor Bishop has given us three lectures so far, and it's such an immense honor to learn from a Nobel prizewinner and UCSF Chancellor...it's such a shame that I usually sit there half-dazed and eating oatmeal from the hospital cafeteria at 8 am in the morning.

Tonight, while "studying," a few classmates came up with some "questions" for Chancellor Bishop the next time that he lectures. Most of the questions refer to the fabled Nobel medal (or "nerd bling"). Is it acceptable for Nobel prizewinners to walk around wearing such hardware?

EIGHT QUESTIONS FOR CHANCELLOR BISHOP DURING LECTURE

1) "Excuse me, Chancellor Bishop, your lecture on viruses and cancer is very interesting. Are you wearing your Nobel medal under your shirt right now?"

2) "Exactly how big is your Nobel medal?"

3) "Can I touch it?"

4) "Chancellor Bishop, is your Nobel medal a bronze, silver, or gold?"

5) "Is your Nobel medal dark chocolate or milk chocolate?"

6) "Do you think that a Nobel medal has improved your 'game' with the ladies?"

7) "Do you sleep with men, women, or both?"

8) "What is my risk of dying from rickettsia in the laboratory?"

Half Moon Bay Pumpkin Festival

Self-explanatory photo

Visited the Half Moon Bay Pumpkin Festival today with Paul and it was lovely. I love autumn and Halloween, so it was great seeing all of the pumpkin patches and little kids dressed up in creative costumes. There was a monster pumpkin, a small-town parade at noon, and a pumpkin pie eating contest.

Samovar

Samovar Tea in the Castro

The second Micro midterm was on Monday, but I didn't start reading the syllabus until Friday night. Although it was an interesting weekend as usual (full of cramming and swearing and all manner of tomfoolery in the S-rooms), I DID manage to stage a coup on Saturday afternoon...usurpring Paul's position as proud President of the UCSF Slackers' Club (a semi-fictional club founded by former M1's who realized that Pass/Fail really means Pass Now/Pass Later).

As Vice President last year, I was fired from my position when it was discovered that I was reading the Placebo chapter the day after the Placebo lecture. After a long summer of doing nothing, I was reinstated this year, only to discover that now my study habits are worse than Paul's (which is really, really remarkable). There's been a lot of power struggles in the Slackers' Club lately, but I will keep you posted on any promotions/fall-outs that occur.

Anyway, local politics has nothing to do with this post...what I really intended to write about was how I visited a local tea place called Samovar in the Castro this afternoon with DSL and drank some really good chai and an oolong dusted in licorice powder. The best part was riding a scooter there! It was awesome.

Now I am at home, thinking that I need to (a) prepare to MSP tomorrow, I am teaching "The Hand"; (b) do some prep for the Synapse meeting tomorrow; and (c) read and do my biostatistics homework. Stan Glantz teaches a course in biostatistics at UCSF, and I am auditing the class with Paul (yay) for fun. Just wanted to post because I wanted to write down a quote from the Primer of Biostatistics that reminds me how cool and insightful Stan Glantz's writing can be:

"The P value is not the arbiter of truth, but rather an assistant in making evolving judgments as to what the truth is" (pg 121).

Rage

Meet Rage, a 17-year-old girl living on the streets of San Francisco who survives by "turning tricks" and living with her friends in abandoned buildings. She comes into clinic complaining that "it hurts when I pee." She ran away from home about a year ago and complains of stomach pains because her last meal at McDonald's was 2 days ago. She wants meds and she wants to leave.

Last week, we interviewed Rage for our Foundations of Patient Care (FPC) class. In FPC, we interview "standardized patients" (highly trained actresses) to practice our communication skills in difficult situations. For med year 2, the FPC gods threw us into the fire quickly, and we learned how to sensitively build a sexual history and watched videotaped scenarios involving personal issues. For example, how should a family doctor behave when his male patient asks for a Viagra prescription in order to have an affair (and his wife is also a patient of the doctor's)? Is the doctor "enabling" the husband to possibly acquire an STD which may endanger his wife's health? Is the doctor allowed to refuse writing a prescription on moral grounds?

Interviewing teenagers is a tricky task, my classmate and I had to convince Rage last week to stay for an hour and attempted to elicit a full medical and sexual history. She refused to talk about why she ran away, constantly distracted herself, and shot back questions (Q: "Are you sexually active?" A: "Are YOU?"). We finally convinced Rage that it was in her best interest to answer our questions so that we could give her the correct medication, explained why we needed a urine and blood sample (for UTI's, pregnancy test, HIV test, STD testing, and a regular CBC). Then we had to explain why we needed to do a pelvic exam. Luckily, she "consented" and we received our "lab results" on a sheet of paper after she left the room. Sometimes, these Problem Based Learning (PBL) cases are eerily similar to those "Choose Your Own Adventure" games that you play when you're a kid.

Rage's tests revealed that she is HIV+, and today's FPC involved a different set of students breaking the news to her during a second clinic visit.

Sniffing Agar

"Is this pseudomonas aeruginosa?" I asked, looking at an agar dish colored blue-green with bacterial colonies during micro lab.

The bacteria supposedly release a "fruity" odor.

Okay, I took a HUGE sniff of the bacteria, probably inhaling some into my nasal cavity.

Nope, just smells like bacteria.

I tried smelling a different agar dish growing pseudomonas.


Yep, smells like grapes if you take a whiff. Don't hold the plate up and inhale deeply.

Hello, October

Not much to say about life in medical school, except that it's a continual 2-week cycle of studying for MSP, pretending to study, trolling websites for Synapse article ideas, doing biostatistics homework, eating out, drinking boba, and then cramming lots of bugs and drugs into my brain for a 3-day-long weekend study binge before the exam. This cycle repeats every 12-14 days. Ah, the life of a second-year medical student. :) Soon, Boards will take over my life in March and then we start rotations in the hospital in April! No time to dwell on that, it's October (isn't "October" a wonderful word?) and I have promised to stop complaining about how the MS1's suffer from a strange form of mass hysteria before the first midterm this Friday. We were once wet-behind-the-ears MS1's, too, and it's always hard to understand exactly how much the examiners expect from us on the first exam. As I remember it, my motivation to study dropped precipitously after the Prologue midterm and my study habits have never recovered. :) Time to dress up in costumes and eat candy!

A Leaf Falls

From the folks at Southwest.com

The Southwest folks have really tickled me with their autumn photography, especially the last one involving a lighthouse and a marsh. Although I'm usually a huge fan of autumn, I'm actually really sad and reluctant to let go of this precarious September hanging between late summer and early fall. It's like that second after you hold your breath and before you jump into the water.

Always Behind

Lavender sachets!

This entry is not going to be very meaningful, just wanted to drop a line.

Mentoring Each Other

Found on Hippie Hill in Golden Gate Park, 9/24/07

Just got back from a large audience interview with the UCSF Chancellor, J. Michael Bishop, author of an autobiography entitled, "How to Win a Nobel Prize." A nice lady interviewed and asked him questions in the newly renovated Cole Hall, and Dr. Bishop seemed to be a fairly charming and thoughtful guy.

Some excerpts (not verbatim, paraphrased loosely):

Bishop: "How many of you here are from dental [some cheers], medicine [few cheers], nursing [few cheers], or pharmacy [big cheer]. Great, we'll allot funding accordingly."

Bishop: "Cancer research progresses so quickly; being in the field is like driving a speeding race car."

Bishop: "I had never heard of the word 'tag line' until two years ago. Anyway, our new UCSF tag line is 'Advancing Health Worldwide.' Which is much better than Johns Hopkins tag line: 'Imagine.'"

Interviewer: "If you had another 40 years to do research --"

Bishop: [in utter mock astonishment] "You mean I DON'T??"

Interviewer: [polite brush off]"If you had another 40 years to do research, what would you work on?"

Bishop: "I wrote a paper during my third year at Harvard Medical School about two medical illnesses that I would like to see elucidated. One of them was cancer, which I have spent my career on, and the other is schizophrenia. Unfortunately, I don't think that I will see the latter elucidated in my lifetime."

Bishop: "In college, there was a physics professor whom I idolized. He said that I was bright and asked me why I was going into medicine, since doctors are just well-trained plumbers."

Anyway, those are the quotes that caught my memory. Another interesting topic that Dr. Bishop spent a lot of time talking about was the concept of mentorship and how important it is. Mentoring is more than giving advice, it's about believing in someone else and advocating for the advancement of that person's career. And, even more interestingly, Dr. Bishop brought up the idea that the most important mentorships occur not between student and teacher, but rather between peers, and that he learned so much more from his peers at HMS than he did from the faculty. He recalls sitting in back while his classmates critiqued the lesson, and how their involvement in research led to his initiation into the world of academic research.

It really touched me, because I feel like I have been very lucky to have so many people in my life who have fostered my growth. And I also realized that my friends in medical school have become some of my most valued mentors.

Obviously, I would never have survived beyond infancy without the love and support of my father and mother, who still sends me newspaper clippings to read and taught me to value creativity and really believed that I could do great things...her nurturing helped my brain make it to Harvard and everything that I do in the future will be thanks to her. In college, I didn't really have a Mentor with a capital M, but there were definitely several professors, teaching fellows (TA's in normalspeak), and classmates who changed the way that I think and encouraged me to continue writing and dreaming. At Stanford, I realized the value of a real mentor, and it saved my life in many respects. Almost unconsciously, also, the attitudes and skills that I learned at Stanford...the expression of "unconditional positive regard" that FPC likes to coin, became part of my outlook and I realized that taking pride in other people's accomplishments and encouraging their potential -- in short, seeing others succeed -- is an amazing high.

Perhaps more on this later.