Thursday, December 24, 2009

Santa in China

Happy holidays! Best wishes for a warm and joyous new year. :)

-Stephanie

Monday, December 21, 2009

New Paper!

Recently published in the Journal of Translational Medicine:

http://www.translational-medicine.com/content/7/1/105

A big THANK YOU to my PI and mentor, Dr. Albert Koong.
And Congratulations to Albert on his recent promotion at Stanford! :)

Thursday, October 29, 2009

Quick Update

Currently home in Los Angeles preparing for Step 2 CS (the exam that is offered in only a handful of U.S. cities, costs $1500 to register, and uses actors as patients).

Currently recovering from a flu-like illness, ironically not contracted while in the hospital.

Currently excited about Halloween!

Friday, October 23, 2009

essential = unknown

"Essential mixed cryoglobulinemia: A condition in which cryoglobulin proteins which are a mixture of various antibody types form for unknown (essential) reasons."
http://www.medterms.com/script/main/art.asp?articlekey=14265


Ironic and somehow apt -- how we use the word "essential" to mean "unknown."

Thursday, October 08, 2009

flashback

from some written thoughts during the first year of medical school (2/2007):

"I guess what I'm trying to say is that there are a lot of things in my life that still make me happy. I am grateful to be at UCSF, and to have a lot of people in my life whom I respect, admire, and love. Being in medical school has changed my life for the better, I feel everyday like I have a purpose in life, the mysteries and quests and the prospect of making a real difference in the world."

Now that I am a fourth-year student, it's funny that I still feel that way.

Tuesday, October 06, 2009

How Science Publishing Works

From SMBC, "Saturday Morning Breakfast Cereal" by Zach Weiner, shown under fair use.

Thursday, October 01, 2009

By the No.

My deep-body radiation dose for the month of August during my IR rotation: 350 mrem.
(range 50-800 mrem according to the radiation safety officer).

Wednesday, September 30, 2009

Harvard Class Report

Every few years, Harvard's dedicated class secretaries will send emails. Most of the time, these contain some form of panhandling, but today I received an email from the class of 2005 about submitting essays for the Class Report. One of the amusing things about Harvard is that the Institution loves its obscure, time-honored rituals and idiosyncrasies (the old incompatible 16-point grading system which was abolished sophomore year comes to mind), most of which are unknown to me until someone tells me that it's time to do it.

Today, I received an email about the November deadline for the Class Report. I have never heard of this "Red Book," a collection of updates on the lives of my classmates to be written, published, and disseminated every five years until at least the 50th reunion. As the article suggests, it does seem to function as a "collective personal diary" or glorified class reunion paper bound in red leather (very dark ages, charming).
http://harvardmagazine.com/2007/05/red-books-raw-gems.html

Several things came to mind:
1) i have a writing assignment from a school that i already graduated from?
2) is it almost 2010 already?
3) good thing that i changed my alum status to class of 2006 so that i can worry about it next year!

Friday, September 18, 2009

Valuable Teaching

Currently on neurovascular ICU at Moffitt and enjoying it. The residents are amazing, the faculty are wonderful and the teaching is impressive and inspiring. In fact, everything about the neurology program at UCSF is inspiring. Tomorrow will be my third day off in 3 weeks, but neuro has been a very formative experience that will help me be a better doctor.

Valuable teaching:
1) from neurovasc fellow: stop using algorithms to treat patients, use them as guides but remember that every patient is different with different treatment plans. being able to manage complex patients and make complex decision-making is the difference between a great doctor and a mediocre one.
2) a good history and physical is the foundation of any good management plan
3) stop giving patients multivitamins, it's just one more pill (again, see rule number 1)
4) always localize the lesion first
5) learning how to sift through information is more important than coming up with the diagnosis when you are learning
6) diagnosing patients early can still help them plan their lives, even if there is no treatment
7) enjoy your life
8) Find your platform

Tuesday, September 01, 2009

evolution lite

ironically, from the NYT
"The results underscore the importance of avoiding the breezy generalities of what might be called Evolution Lite, an enterprise too often devoted to proclaiming universal truths about deep human nature based on how college students respond to their professors’ questionnaires."

Friday, August 28, 2009

Mission Bay

See article below about the newest neighborhood in SF, Mission Bay. I recently moved into UCSF housing at mission bay and have been enjoying the location. Not only is the weather warmer and sunnier, but the UCSF campus is in close proximity to the Giants ballpark and Philz coffee (albeit not as tasty as the Philz in the Mission). Also, MB is close to the freeways and the Bay Bridge for easy access to south bay and Napa. One downside of Mission Bay is the lack of restaurants and relatively higher levels of crime compared to the inner sunset. However, Mission Bay will be growing very rapidly in the next few years, especially as UCSF pumps more cash into the area and the new women's/children's/cancer (not quite sure how those are related) hospital becomes completed.


Mission Bay becoming a real neighborhood
Meredith May, Chronicle Staff Writer
Wednesday, August 26, 2009

It's a Wednesday morning in San Francisco's newest neighborhood.
As construction workers raise steel into place on emerging high-rises, a man blasts a serve on the beach volleyball court under the Interstate 280 overpass.

Biotech workers and suited professionals crowd the bar at Philz Coffee, where tattooed baristas place mint leaves on steaming cups of individually filtered coffee.

Retiree Toby Levine surveys the Mission Bay morning from her high-rise terrace, where signs of a community are finally starting to emerge.

It's taken four mayors and three planning directors to create what is now the last swath of San Francisco land where planners can create a neighborhood from scratch. So far, 3,000 people have moved into the 300-acre rail yard south of the Giants baseball park. The neighborhood is 35 percent built, and 15 years from now, it's expected to have 11,000 residents.

Mission Bay feels as if it escaped the economic downturn - stores are opening, buildings are going up, and young professionals are zipping out of $700,000 condos to get to work. Most live in a six-block area north of Mission Bay Creek. These pioneers say it's now starting to feel like a place worth staying in on the weekends.

"It's changed a lot. It's way more crowded now," said Claudia Arrenberg, 27, who shopped for pasta and fruit with her 2-year-old daughter at the new Mission Bay Farmers' Market.
She moved into UCSF student housing with her husband in 2005 so he could study neuroscience. But it was such a ghost town that they moved to Alamo Square, even though it was more expensive. They returned in 2008.

There's a public library, senior housing, a Safeway beneath the offices of the California stem cell research headquarters.

Half of UCSF's 12 buildings are completed, and dog walkers and parents are beginning to draw battle lines over the patches of park.

"We got more families than we expected, many couples with kids who commute to the South Bay on Caltrain," said Kelley Kahn, who manages the Mission Bay project for the San Francisco Redevelopment Agency.

"We thought we'd see more people in their late 20s, but it's older parents starting families and retirees wanting to leave the hassle of owning a house."

Levine is one of those retirees, who, after 40 years in the Mission District moved to a Mission Bay apartment in 2007 with her husband.

She began pushing for a tot lot after she discovered that there are 300 children in Mission Bay, but there's no playground.

"I like the adventurousness of starting something new at my age, and being in the middle of a tremendously important development for the future of the city," said Levine, 75.
Mission Bay is expected to create 31,000 new permanent jobs that range from retailers to biomedical researchers.

Levine has found it difficult to create community in Mission Bay, and she figures that's because the young professionals who work so hard to afford to live there just want to close their doors and relax at the end of the workday.

It's an investment to move to Mission Bay - condos start at $600,000 and go up to more than $1 million.

Nearly one-third of Mission Bay's homes will be reserved for low-income families, more than is required by law, Kahn said.

Below-market rate
Mission Walk - a two-building development with the first below-market-rate homes in the neighborhood - is set to open in September. Nearly 650 people applied for one of the 131 townhomes and condos, which were priced from $149,000 to $302,000.
The Mission Bay of the future will have 6,000 homes, a 43-acre UCSF campus that includes a 550-bed hospital, 41 acres of new parkland, 4.4 million square feet of biotech and lab space, and 500,000 square feet of retail shops. It will have a 500-room hotel and a public school.
Residential construction south of the creek has slowed, Kahn said, because developers can't get financing.

"If the economy is worse than we thought, and it stays this way for five or seven more years, we'll be in trouble, but right now we are OK. We have money in the bank," she said.

Monday, August 24, 2009

mmm, steak!

"I have to read your blog to find out what you're doing." - my mom

today was relatively quiet in IR, we had vietnamese sandwiches for lunch and they were great. for dinner, my lovely roommate christine and her boyfriend jason made filet mignon from costco, and it was DELICIOUS.

man, i really have to work on my ERAS application. :P

Thursday, August 20, 2009

IR

currently loving IR, just got back from the longest work day (12 hrs). We had six cases (a PEG tube, a central line and feeding tube for an ICU patient with an infected vascular graft, two aortograms and angiograms of the legs, and then two emergency cases involving an HIV+ man in acute renal failure and AMS requiring an emergent dialysis cathether and a man presenting to the E&A with a large perirectal abscess communicating with his bladder).

i am enjoying the demographic at the VA -- generally salty men with a good sense of humor and high tolerance for pain. On the carpet in front of the main entrance, there is a rug printed with the words, "the price of freedom is visible here." not quite sure yet how i feel about that.

wisest words today from a patient/former carpenter:
"one thing i've learned...leave good enough alone."

resident replied, "yes, the enemy of good is better."

Thursday, August 06, 2009

A WhIRl of Activity

Finished my ED rotation last week and started my IR rotation at the VA this week...during the weekend I managed to complete two ED shifts while moving into a new apartment at Mission Bay!

Since this is my first time at the SF VA, there are a few observations:
- veterans tend to belong to a specific demographic
- veterans tend to pretty stoic about their medical conditions (example 1: "does this hurt?" [jab a needle] "Nope." example 2: "any medical problems?" "Nope." the note says he has HCV. These are two different veterans).
- the oceanside view is sublime
- the commute along the Great Highway is also pretty uplifting

Overhead, just heard a funny announcement over the loudspeaker:
"Mr. H. Mr. H, please return to your room, Room 1A."

Sunday, July 19, 2009

funniest quote of the day

from a nyt article on the booming college admissions consulting business:

“It’s annoying when people complain about the money,” the Vermont-based counselor, Michele Hernandez, said. “I’m at the top of my field. Do people economize when they have a brain tumor and are looking for a neurosurgeon? If you want to go with someone cheaper, or chance it, don’t hire me.”

couldn't stop laughing.

Sunday, July 12, 2009

zone 1/2

finished my third shift in zone 1 at the SFGH ED, it was very busy (the way i like it) and full of new developments. one of the most surprising cases was a 55 F who came in c/o left flank pain, we thought that it was a UTI resistant to the ciprofloxacin that she was taking, but my ED attending suspected diverticulitis and the pt got an abdominal CT that revealed a right cystic ovarian mass concerning for ovarian cancer. after informing the patient of the CT results, I questioned the patient further and found that she has been experiencing abdominal bloating for two years and a sensation of abdominal fullness. she had never been pregnant. all of these symptoms (insidious and innocent as it seems) are all risk factors for ovarian cancer, and after the radiology results, things started clicking in place in a serious way. it was really sad.

working in the ED is nice, I really enjoy the fast pace and being busy busy busy while i am at the hospital (downtime is not as fun for me, although i do need my coffee ritual in the morning). the other aspect that i am really relishing is the speed of test results (labs, CT, etc), the decision-making and diagnosis, as well as discussing the plan with nurses, consult teams, attendings.

Friday, July 10, 2009

Needlestick update 1

Thanks everyone for the well wishes. :)

I went to occupational health this morning to have baseline labs drawn and consented to have a "student phlebotomist" draw my blood. hey, we all gotta learn somehow (although most of the time in med school phlebotomy class, the learning is mutual). the student phlebotomist was nervous, but pretty fast. after the blood draw, the nurse supervising her growled, "you have to make sure that the whole needle is in the sharps bin." we looked at the table and realized that the entire butterfly needle was still hanging outside the bin. Hm. The sight of such a needlestick hazard made me wince (on the inside).

Wednesday, July 08, 2009

"Stuck" in the ED

Yesterday was my first day in the SFGH ED as a sub-intern. I really enjoy the fast pace of the emergency room and the ability to triage and decide on preliminary tests for my patients. By the end of five hours, my head was pounding from the chaos and competing interests of different patients (next time, carry tylenol in my pocket).

Another nice thing about the ED is the number of procedures that you can do. By the end of my shift (7/7, 9:10 pm), I was attempting a lumbar puncture on a woman suspected to have meningitis. After inserting a 20-something gauge needle filled with lidocaine to anesthetize her back, I capped the needle using the one-handed scoop method. Then I tried to unscrew the needle to replace it with a longer needle in the LP kit. But the needle would not unscrew from the syringe. I made a twisting motion, which in retrospect only loosened the cap from the needle, and subsequently felt a familiar sting (after being phlebotomized by classmates so many times). I had stuck myself in the tip of my left index finger with a dirty needle.

"I think I stuck myself," I told the resident calmly, setting the syringe down and walking away from the patient while watching the blood welling underneath my glove tip. My first thought was, "Good thing we got a rapid HIV test before doing the LP." The resident was incredibly considerate and advised me to run my finger under running water for five minutes before calling the needlestick hotline (in retrospect, I would recommend washing with soap and water, running your wound under a faucet for 5 minutes, and maybe splashing some alcohol or betadine if you're extra paranoid).

While holding my finger under running water, I stared at the clock and began rapidly running through the patient's medical history again in my mind. 35 F c/o 3 days of fever and headache. 10/10 occipital headache with pain on neck flexion. no trauma. T 38.7 on arrival. What were her serologies? Is this an acute primary HIV infection? What is the NPV of a rapid HIV test in the SFGH ED? I felt unnaturally detached.

I was also extremely peeved at myself for making this mistake, because I usually pride myself on being careful during procedures. In fact, the smoldering annoyance has not faded today, and I still feel like an idiot. In retrospect, most needlestick injuries occur when you are recapping a needle (hence the scoop method) or disposing sharps, and the injury occured probably because I was attempting to unconsciously recap the needle before the needlepoint was exposed after seeing the cap slipping. Unfortunately, the lidocaine needle is a lot shorter than the IV needles that I have grown accustomed to using. When speaking to the ID fellow, he advised me that one of the most common needlestick injuries occur after screwing the needle too tightly into the syringe.

Needlesticks are extremely common in the hospital, but in the SFGH ED, it was especially scary. Most of my patients have HIV, HCV, or both, and this patient was a black box. It was also concerning for me to realize that we still had no idea what her diagnosis was.

Since today was my day off, I was able to read some personal accounts of other doctors and nurses who have joined the Private Misery Club and some of them are quite moving, funny, thoughtful, and some just depressing. Many talk about mortality, or the sensation of a lost future. Some of my first thoughts after the needlestick involved my future...what am i going to do now? can i practice medicine in the future? what about unprotected sex? and then maybe a few times I mentally uttered my favorite curse word of all time: fuck.

It is not a good time right now to wax philosophical about mortality or medicine; I have an appointment on Friday for some baseline labs. The patient's rapid oral HIV was negative, and I have been told today that her serologies were negative, but that doesn't ease my concern that this patient has acute primary HIV infection given her suspected meningitis (which can follow the prodromal flu-like illness) and considering our ED population enriched with blood-borne diseases. Argh. If there is one thing that I hate more than uncertainty or regret, it is having the patience and attention span required for surveillance serologies. The ED requires neither patience nor an attention span longer than 24 hours, which might still be ideal for me.


My favorite personal account of a needlestick injury is from Buckeye: http://ohiosurgery.blogspot.com/2008/10/needle-stick.html.
There's a nice one from an ED physician: http://gruntdoc.com/2005/05/needlestick.html
And a blithe one from an MS2: http://www.boston.com/yourlife/health/blog/2007/10/ill_have_what_s.html

Monday, June 15, 2009

perfect weekend

i'm not sure yet what "living the dream" means in medicine jargon, but just finished a perfect weekend (thanks to paul and costco):
saturday: philz coffee, driving over golden gate bridge to napa (mondavi, stag's leap -- cask 23 is uhmazing), napa outlets, spicy dinner in berkeley
sunday: philz coffee, casual walk to SF Giants game for $10 seats in the view box behind home plate, 9-hole game of golf at Golden Gate Park, and watching the movie "Up" in 3D using $7.50 costco tickets.

most people do not know where the heart is

recent study in BMC Family Practice showing that less than half of 722 Britons surveyed can identify where the heart is on a diagram.

http://www.cnn.com/2009/HEALTH/06/15/body.knowledge.survey/index.html

reminder to self: draw more pictures for patients

Tuesday, June 09, 2009

Radiology

Currently on a didactic radiology rotation for the next month. Medicine at SFGH was great, and I look forward to working in the ED next month (read: avoid the ED next month).

Currently watching basketball.

Thursday, June 04, 2009

osborne wave!

Craig showed me the coooooolest EKG this morning of a 58 M "found down" in the tenderloin. rectal temp 24 degrees celsius. he had very large and distinct osborne waves!

It was very exciting to see real osborne waves for the first time, like reading someone's biography and then meeting them in person for the first time. Do people still read biographies?

Thanks, Craig!

Wednesday, June 03, 2009

reflections on a "stabbiversary"

extremely well-written reflection on near-death experiences from NYT blog. curiously, this author was stabbed in the neck with a stiletto 14 years ago...

"You can’t feel grateful to be alive your whole life any more than you can stay passionately in love forever — or grieve forever, for that matter. Time forces us all to betray ourselves and get back to the busywork of living in the world. Before a year had gone by the same dumb everyday anxieties and frustrations began creeping back. I’d be disgusted to catch myself yelling in traffic, pounding on my computer, lying awake at night wondering what was going to become of me."

http://happydays.blogs.nytimes.com/2009/06/02/reprieve/?em

Monday, June 01, 2009

"Winning the Game"

In medicine, "winning the game" means that a team or person has discharged all of their patients before the next call night, which means that they have no work until the next call. Clinical medicine is an interesting culture, with slang and neologisms that can roll off your tongue before you can think, "wait, that was incomprehensible to a normal person." For instance, you can say, "CBC q 6 hours, goal crit 30" or "cycle the trops" or "wean the nebs" and most people around you in the hospital will nod knowingly.

But i often digress. Medicine at el general has been great, I really enjoy working with my team and treating patients who are often underprivileged and have complex psychosocial situtations. The residents and attendings at SFGH are fantastic, and provide top notch care to patients who can easily fall between the cracks.

Monday, May 11, 2009

Medicine Sub-Internship

Currently a sub-I at SFGH, please don't get sick in the next month or you might see me.

Recently registered for step 2 USMLE.
Warning: CS costs $1,055 alone to register and CK costs $495. That doesn't include the mandatory travel to LA or lodging.

Recently bought an i-pod touch to enjoy epocrates...my first apple product. Got absorbed in installing apps and was reading through Yelp, found out that there are many patient reviews of UCSF Medical Center. It's so interesting read those reviews, which are either 1 star or 5 star (max)...which makes sense since you only make the effort to type something if you are extremely satisfied or ridiculously angry.

Some observations of Yelp feedback: Interestingly, the polarized reviews had many themes in common. The 1-star patients usually are in general good health with minimal contact with healthcare, coming in with a musculoskeletal complaint (eg xray for foot/hand, sprain or acute flu with SOB) to Urgent Care (oohh, lots of ire). The main complaint is waiting time (up to 8 hrs) in the ED, brusque staff, lack of parking, billing, hospital food, etc. There were very few complaints about doctors' care (except for one woman who was turned away by an ED physician for SOB), and no complaints about residents or trainees (except one patient cited the lack of continuity with residents in clinic).

Patients who write 5-star reviews generally have serious/chronic/rare ongoing medical conditions. Some families will write on behalf of patients. One reviewer wrote on behalf of a friend who had heart surgery, another patient was grateful for the teaching program regarding kidney transplants, etc. One patient noted that the lab reports for rare diseases will be processed faster at UCSF than at other hospitals. Some patients who had life-threatening conditions praised the ED.

Reading that uncensored feedback might be a good exercise for our hospital administration to see what can be improved. We can score big points with patients if we make the logistics of getting healtcare more convenient -- making appointments online and keeping clinic wait times within 1-2 hrs (or the pizza is free!).

Sunday, May 10, 2009

Friendly PSA

Call your mother today!

Remember that the US postal service raises prices on stamps to 44 cents tomorrow!


Thursday, May 07, 2009

Reflections on Third Year

"So what should I know for third year?" someone asked me recently.

Whoa. Wow. Um. Where to begin?

Undoubtedly, the third year of medical school has been the most memorable experience thus far in my life, and even now when I reflect on all the crazy and outrageous and wonderful and awful things that I've seen, I can't even believe that it happened to me and not some 2D person on "Grey's Anatomy." In psychiatry, they might call that derealization.

Being a third year medical student is like being a guppy in the hospital ocean. You wander around helplessly, trying to learn how to coexist in a complex environment under some very talented and harried residents. It can be totally confusing and bewildering, but it also opens the door to levels of opportunity and privileged intimacy with strangers previously unheard of. Sometimes, third year feels like an apprenticeship where you learn things using your hands and watching others. Other times, it can feel like boot camp or pledging a fraternity. In many ways, you learn things about yourself and other people during your first year on the wards...and none of these lessons can be easily transmitted verbally...it's almost like everyone has to undergo a second awkward adolescent period as a rite of passage. Also, being a third year medical student was like regressing back into being a 4-year-old child, because the medical world is often alien to the newcomer and learning how to be a doctor is like learning how to be an adult all over again...how to speak medical jargon in surgery vs. psychiatry, how to be polite (pager etiquette), how to follow rules, how to learn what might be important (lab values, complaints) and what is unimportant when listening to a story -- simple things that seem obvious to the indoctrinated.

What also amazed me was how simply being a third year student opened doors in the hospital... From being a mere college graduate with an interest in medicine to someone invited to scrub in on surgeries, write notes, interview patients, perform IV insertions and intubations, and witness the miracle of birth...I learned halfway through third year that simply saying, "I'm a medical student, can I watch?" led me to opportunities beyond imagination.

Third year is hard, I definitely feel slightly burned out, but surprisingly my cynicism has not worsened. If anything, I've shed a little bit of my "beat around the bush" mentality. It was more difficult to blog about third year than anticipated, mostly because of time constraints but also because of privacy issues (HIPAA etc). If I had more time, I would write out paragraphs of my ten most memorable experiences this past year, but instead will list them in no particular order:

1) participating in a liver donor run to New Mexico over Thanksgiving
2) scrubbing in on liver transplants
3) befriending a boy with a giant retroperitoneal tumor in rad onc and crying outside the OR after hearing that it was wrapped around his aorta
4) taking care of little kids in peds urgent care
5) watching babies being born in fresno
6) inserting a 14-gauge IV into the dorsal hand vein of a patient under the curtain on anesthesia
7) chasing after a psychotic HIV+ transgendered patient at SF General on psychiatry
8) participating in my first code while scrubbed in on a vascular surgery in which the patient had an MI on the table...he was placed on ECMO
9) learning from medicine to "always do what's right for the patient" and to talk to unconscious patients as though they were awake, even though it seems strange, it's a sign of respect.
10) watching the work-up of a patient who turned out to have Q fever endocarditis

Saturday, April 04, 2009

Philz Coffee

For the past few weeks, Paul and I have been addicted to Philz Coffee. Seriously addicted. My favorite is "Anesthesia to the Upside," because it's very mellow, sweet, and nutty. Other good ones are Ambrosia, Tesora, and Aromatic Arabic (dark roast).

http://www.philzcoffee.com/

At first sip, you will fall in love and get a huge caffeine rush. I've never had coffee that was so flavorful and well-blended, and they make each cup one at a time with heavy cream and brown sugar.

The mini donuts are also tasty, especially Meyer Lemon.

There's a new store in Palo Alto, too! :)

Go drink coffee now! And then eat BiRite ice cream! :)

Wednesday, April 01, 2009

Do Not Use Dirty Needles

My neuro ICU patient is currently suffering from MRSA bacteremia and endocarditis, with mycotic aneurysms in her brain causing intracranial hemorrhages. She is an IV drug user with hepatitis C and she's 30 years old.

After seeing many patients with a history of IV drug use, a staggering proportion of patients have hepatitis C, HIV, or both. Many patients have infections from dirty needles, like my patient.

Kids, just say no to drugs. But please, do NOT INJECT DRUGS. It's possibly the worst imaginable method of ingesting substances for tons of reasons (outlined below), but it also happens to give people the quickest and most intense effect (partly because it increases bioavailability by bypassing the gut). It's impressive to me that much of the morbidity arising from IV drug use (IVDU) arises from using dirty needles...
- Hepatitis C - very common
- HIV - pretty common
- MRSA, infections, etc
- higher risk of overdose
- nerve/artery damage

Never use needles. Stay away from drugs. Can you tell that I'm venting?

Sunday, March 29, 2009

Psych!

"Third year sucks," an intern once told me in the middle of third year.

"Really? Why?" I said (wow, way to go, Stephanie).

"Because you're constantly changing into different clinics and doing different roles and working with new people with no idea how to think or what to expect until you get the hang of it after a few days and then you're shoved into a totally new setting with a different set of practices. And the whole time that you're struggling, everyone around you is critically judging you."

Never really considered that, but it's a good synopsis of why third year can be challenging. The other aspect not really mentioned is that third year can be hard because there is a huge lack of personal free time and a sense of social isolation compared to the first two years of medical school. But it's not all bad news, ladies and gents.

Once you get the hang of third year, however, it can be exciting and fun! Imagine going to a chocolate salon and sampling every bite of chocolate. That was fun last week, until I got really nauseous.

Third year is like a cultural safari where you can study different tribes, adopt their customs, and learn how they think and what their values are. For someone who is adventurous and flexible, resourceful and resilient, third year is like a grueling backpacking trip through the Amazon where the locals are concurrently evaluating whether or not you should be allowed to go traveling. But the best part is that you don't have to travel very far at all...in fact, you tend to stay in one building for 13 hours per day.

Another interesting group that you get enormous exposure to is your patients. I have always suspected this before, but the strength of any medical training (and thus medical school) is heavily based upon both the skills of the residents AND the diversity of your patient population. Pick a medical school based on geography and the patient population that you get exposure to, because that will shape your training as a doctor. At UCSF, we are enormously privileged to have several settings (VA, Moffitt, SFGH, CPMC, Fresno) that gives us a wide range of patients from all walks of life....young/old, rich/poor, urban/rural, etc/etc. Working at SFGH has been an amazing experience, because it is the only hospital in the city that serves the uninsured, the only trauma center in SF, and the cradle of HIV/AIDS healthcare. It is estimated that up to 25% of the patients at SFGH are HIV+ and SFGH is home to Ward 86, one of the most renowned HIV clinics in the country. Going to medical school in SF allows you the unbelievable privilege of working with a large HIV+ population in SF and gives you insight and medical training that cannot be replicated, and I never TRULY appreciated this until third year.

Okay, I've totally digressed again. All of this was a prelude to a short reflection on my time on inpatient psychiatry at SFGH. It was an excellent experience, and I learned so much about how to interview psychiatric patients (be nonjudgmental, ask questions like Columbo) and how to think/adminster psychiatric medications. In fact, the inspiration for this posting was a recent UCSF news tidbit on how the drug company Eli Lilly is trying to market a new combo drug (olanzapine and prozac) for treatment-resistant depression. Psych is so incredibly interesting, and I predict big advances in the next 50-100 years as we learn more about the pathophysiology of schizophrenia, bipolar, depression.

Oops, gotta go.

Monday, March 16, 2009

hey, i got my stuff back

Believe it or not...but I got a call from a medical classmate letting me know that my stolen tote bag was dropped off "by a homeless guy" at the Moffitt ED. Most of my stuff was still there (!) including:

- psychiatry case files book
- medical student ID
- stethoscope
- reflex hammer
- key
- pager
- two notebooks
- chapstick
- umbrella

The only things missing that i can tell so far were a cliff bar, the battery from my pager, and a pack of 50 cards for 1-800 quit tobacco. Found objects include a BART card and a flyer for a tattoo parlor.

Not sure what to make of this...maybe the man who smashed my car window realized that he stole a bag from a painfully dorky medical student and took pity on me?

Thursday, March 12, 2009

boosts

Last night my car window was broken and my book bag taken as I was eating dinner in SOMA. Bummer. Like any curious medical student, I started almost compulsively googling some background reading and found that these car burglaries or "smash and grab" crimes (known as "boosts") are way too common in San Francisco, with an average of 41 incidents per day in the city!

Many medical students have experienced car burglaries even in the Sunset, which is relatively safe, and some have had their cars stolen. It's like owning a bicycle in college....it WILL get stolen! Accepting these crimes as a fact of life is frustrating.

Interestingly, after a campaign to crack down on car burglaries, the police reported that "the team has arrested 34 people, according to department spokesman Sgt. Steve Mannina, which has contributed to a 22 percent drop in incidents reported between October of this year and October 2006."

"By arresting one person, we prevent at least 10 to 20 [break-ins] per week,” Lazar said. “One person doesn’t break into just one car. They move on and target more.”

This week, my car window got broken and I lost all of my psychiatry materials.

Last week, a psychiatric patient escaped from the hospital under my supervision...but he came back six hours later to "get his stuff back"!

Sigh.

Thursday, February 19, 2009

Mnemonic for EKG Lead Placement

Today in anesthesiology, I helped out with the setup for a patient undergoing a whipple procedure for pancreatic cancer. the surgery lasted all day (roughly 8-5pm) and was pretty complex, plus there was a really amazing resected specimen (part of the pancreas, duodenum, with a huge yellow globular tumor). slices of the tumor were sent to a tissue bank and the rest was sent to pathology. but i digress.

after the whipple man was well underway, i tagged along and observed four IVF procedures in which eggs were being harvested from hormonally primed women. then i bounced back to the OR to help set up 2 more patients for a D&C and TVH.

slowly, i am starting to learn how to think like an anesthesiologist. also, i am starting to figure out the myriad of procedures that have to be done in a hurry. during the IVF procedures, it was amazing to think about how marvelous noninvasive inventions like the EKG, pulse oximeter, and even an O2 nasal cannula with CO2 monitors can improve patient safety without harming the patient at all. anesthesia itself has always amazed me...how can a person go to sleep, have their abdomen exposed, have a tumor resected with their plumbing all reconnected...and wake up with minimal pain (thanks to an epidural), alive and kicking? the miracle of anesthesia. amen.

oh wait, i forgot about the title of this post.

so the EKG leads in the OR have 5 leads. on the left side, the resident taught me the mnemonic "smoke over fire," meaning that the red lead is below the black lead (and the brown lead is in between, pretend it's wood if it makes you feel better). on the right side, the green lead is below the white lead, so I have decided to make my own mnemonic: "snow falling on cedars." okay, okay, I know that the biggest criticism of my MSP lessons (based on comments in Evalue) was that I was heavy on the mnemonics, but there are oodles of things in medicine that don't have any intrinsic meaning...like why the white lead has to be white...and why i am spending time typing this ramble when I should be sleeping....zzzz...

Wednesday, February 18, 2009

anesthesiology

Currently on a 2-week anesthesiology rotation at mount zion, and it's pretty cool so far. During grand rounds this morning, I got the impression that anesthesiologists seem happier than surgeons...! There's a lot of cool procedures (i got to put in an LMA today) and different medications to use, and there's a great emphasis on thinking through the patient's physiology.

Wednesday, February 11, 2009

family planning

Visiting the Family Planning Clinic in Fresno, California, was an important part of our Ob/Gyn rotation and of our medical education. Although most students have mixed feelings about elective abortions, the general consensus appears to be that most students are pro-choice, but would never be able to personally perform abortions. How can there be such a contradiction? It is almost impossible to be neutral or apathetic about the issue of abortion, because everyone has deeply held personal beliefs, personal experiences, and cultural or religious backgrounds that influence how we feel and act.
The doctor working at the Family Planning Clinic was extremely cordial and eager to teach medical students. He encouraged us to ask questions and made efforts to have us observe several procedures. After the embryos were extracted, the doctor had the samples placed in dishes of saline so that we could observe the villi, gestational sac, and parts of a 14-week embryo.
There were several moments during the visit when I was very grateful for the opportunity to visit the Family Planning Clinic to observe an important process that even doctors and hospitals will not openly acknowledge. It also made me aware of how difficult it is to be a woman with an unwanted pregnancy with few options, and how the stigma of abortion can be still be so potent. Overall, the experience strengthened my conviction that legalizing abortions is crucial to women’s health and well-being, because so many women would lose their lives to infection, hemorrhage, and dangerous procedures if safe, effective, and confidential medical procedures were unavailable.
Admittedly, there were also a few moments when I experienced twinges of sadness. Gazing into the saline dish, we could see the gestational sac and 2-centimeter body of the 14-week embryo. The embryo’s head had been ripped apart during the vacuum process, but we could still discern the legs, spine, and arms down to the tiny fingers. When we found the embryo head, the two small eyes seemed to be staring at us with a sad confusion that mirrored my own unresolved feelings.

Wednesday, February 04, 2009

My intellectual mother, part 2

Chatting with my 13 y/o brother....

Jeremy: Mom is too mad to talk right now

me: whoa...why is she mad ?

Jeremy: The book she read was the worst book she ever read

me: HAHAHA

Jeremy: The series was called the dreamers
In the end, they went in the past and killed the enemy
Leaving all the books before useless

Tuesday, January 27, 2009

Tip #3: Pregnant? Go See a Doctor ASAP.

Pregnant women of the world, please see a doctor AS SOON AS you think that you might be pregnant. Not only can you get a second pregnancy test, but you can start your prenatal care early. Fetuses need healthcare too, but the most important thing might be the first sonogram to estimate the age of the fetus. Combined with knowledge of your exact LMP (the first day of your last period), doctors can make better decisions about your healthcare...everything from deciding when you might need an induction to whether your fetus is growing normally.

I always wondered by doctors get very persnickety and anal about "dating" the pregnancy, but now realize that it is a fundamental and often underestimated part of the process.

respect

I often enjoy David Brooks' columns in the NYT, here is a particular quote of a quote for today:

"In 2005, Ryne Sandberg was inducted into the baseball Hall of Fame. Heclo cites his speech as an example of how people talk when they are defined by their devotion to an institution:

'I was in awe every time I walked onto the field. That’s respect. I was taught you never, ever disrespect your opponents or your teammates or your organization or your manager and never, ever your uniform. You make a great play, act like you’ve done it before; get a big hit, look for the third base coach and get ready to run the bases.'”

However, I disagree with Brooks' assertion that we must return to a culture more reliant upon institutional thinking. I am still a big believer in the philosophy of a liberal education, as Brooks points out:

"A few years ago, a faculty committee at Harvard produced a report on the purpose of education. “The aim of a liberal education” the report declared, “is to unsettle presumptions, to defamiliarize the familiar, to reveal what is going on beneath and behind appearances, to disorient young people and to help them to find ways to reorient themselves.”
The report implied an entire way of living. Individuals should learn to think for themselves. They should be skeptical of pre-existing arrangements. They should break free from the way they were raised, examine life from the outside and discover their own values."

Whether we devote ourselves to individualistic "thinking" or institutional "thinking" is not even the point; both labels describe certain automatic behaviors. We need to be capable of thinking (and I say this in italics) in a consciously unbiased manner instead of blindly following our own needs or conforming to the demands of society.

Monday, January 26, 2009

Happy Chinese New Year!

Year of the Ox. :)

Saturday, January 24, 2009

When I Grow Up

The favorite questions between classmates during this season are: 1) Are you taking a year off? and 2) Do you know what you might go into?

No. And no.

Throughout medical school, I always assumed that the right field would seem immediately and obviously perfect for me. Maybe it would be when I diagnosed my first ear infection in a 2-year-old in Pediatrics. Maybe it would be when I first saw an open abdomen under the bright lights in an OR during Surgery. But somehow, working on the theory that finding a medical profession can be as easy as love at first sight has...well...turned out to be harder than imagined.

Writing has always been a way for me to process emotions and explain decisions. But during third year, writing has been difficult due to time constraints, privacy issues, and my inability to sit down and ponder the journey that will be my life.

Stay tuned for future angst.

Wednesday, January 14, 2009

Fresno, CA

Fresno is an inland city located in California's Central Valley approximately midway between San Francisco and Los Angeles. In many ways, Fresno is very different from San Francisco...the median income for a household in Fresno is $32,236 vs. $57,833 in San Francisco according to wiki. There is a larger population of Hispanic and minority patients, and most of the Asian patients in Fresno are the legendary Hmong. (Legendary because Hmong culture is featured extensively in our required reading during medical school as part of lessons in cultural sensitivity, but rarely seen in San Francisco).

In Ob-Gyn, our female patients tend to be younger, healthier, poorer, and less educated than patients probably seen at other hospitals in the Bay Area. A fair amount of patients are illiterate. Many are immigrants from other countries. Learning medicine in a non-academic center has been new and refreshing for me, and I have been able to practice my medical Spanish. I had wanted to do obgyn in Fresno because 1) it seemed like a good idea to do an away rotation to see new settings; 2) Fresno has one of the highest birth rates in CA; 3) I've never been to Fresno; 4) I wanted to practice my Spanish.

I haven't spoken much Spanish since college, and have been amazed again at how beautiful the language can be. Honestly, Spanish is more expressive and beautiful than English or Mandarin...and this is coming from a pseudo-Asian American English major. There are so many shades of meaning, and interesting quirks to think about...like how the term for giving birth is "dar la luz" (literally: give light), or why someone can be "estar muerto" (dead) when the verb "estar" implies a temporary state. Or even why someone can be "ser joven" (young) when "ser" usually implies a permanent state. Don't get me wrong, my Spanish is still fairly poor.

Another interesting thing about Fresno is the lifestyle...the buildings are spread out, there are gazillions of chain stores like Target, Starbucks, Costco, and plenty of parking and free high quality food at the hospital. The people in Fresno tend to be more open, friendly, less pretentious and more humble. :)

Monday, January 12, 2009

Tip #2: Wipe from Front to Back

Ladies, avoid getting UTI's by wiping from front to back (if you know what I mean).

Interesting NYT article on abortions in the NYC Dominican community: http://www.nytimes.com/2009/01/05/nyregion/05abortion.html?pagewanted=2&fta=y

ObGyn is fun! I enjoy working in the clinic and seeing different aspects of female reproductive health. Today I saw a few colposcopies for cervical dysplasia and worked up a case of bilateral breast pain. In the past week, there have been a few endometrial biopsies, some PID, a MRSA abscess, lots of prenatal appointments, and lots of birth control appointments. :)

Wednesday, January 07, 2009

Ladies, Keep Track of Your Period

Current in Fresno on my ob-gyn rotation. Fresno is a cool town, and medical students get free housing! So far, I like how ob-gyn is such a great mix of medicine and surgery.

Public Service Announcement: Ladies, PLEASE KEEP TRACK OF THE FIRST DAY OF YOUR PERIOD. In clinic, less than 25% of women know the date of their last menstrual period (LMP). This is just sad and pathetic, because obviously it's not hard to keep track of your period using a calendar, but rather indicates that medical professionals suck at teaching patients how take charge of their health. This will also come in handy not only if you're pregnant, but also if you show up at the Emergency Room with appendicitis...they will want to know your LMP.

Don't worry about anything more than the FIRST DAY of your period.

Saturday, January 03, 2009

Raise Your Kids in Arcadia, CA

Sorry again for the lack of posts...surgery was busy and full of dramatic stories to be related soon. A belated Merry Christmas and Happy New Year! :)

Also just wanted to let everyone know that my hometown of Arcadia, CA was named the best place in California to raise your kids in 2009 accordinging to Business Week magazine! And the Rose Queen in the 2009 Pasadena Rose Parade is an Arcadia High School student! :)

See links: http://images.businessweek.com/ss/08/11/1110_best_places_for_kids/6.htm

Kid-Friendly and Cost-Friendly

By Prashant Gopal

Welcome to BusinessWeek's second annual roundup of the best places to raise your kids.
This year we are going state by state. Once again working with OnBoard Informatics, a New York-based provider of real estate analysis, we selected towns with at least 50,000 residents and a median family income between $40,000 and $100,000. We then narrowed the list of towns using the following weighted criteria: school performance; number of schools; household expenditures; crime rates; air quality; job growth; family income; museums, parks, theaters, and other amenities; and diversity. We weighted school performance and safety most heavily, but also gave strong weight to amenities and affordability.

Bear in mind with this list, the organizing principle was affordability. While the median household income varies by state, we purposely weighted the results to prevent pricing out most readers. That's why, for example, Greenwich, Conn., with its good private schools, low crime, and abundance of cultural amenities, was left out. It simply costs too much to live there.
Of course, there are other places that are great for kids which did not make this list. In many states the competition was extremely close. Moreover, we looked for communities that scored well across the board. So, while there might be places that offer more culture, better schools, etc., other factors such as crime or a high cost of living knocked them down.