Tuesday, October 30, 2007

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?

Monday, October 29, 2007

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.

Saturday, October 27, 2007

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."

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.

Friday, October 26, 2007

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?

Friday, October 19, 2007

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.

Wednesday, October 17, 2007

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.


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?

Tuesday, October 16, 2007

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?


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?"

Saturday, October 13, 2007

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.

Wednesday, October 10, 2007


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).

Tuesday, October 09, 2007


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.

Tuesday, October 02, 2007

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.

Monday, October 01, 2007

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!