USMLE Step 1 Tips:
1) Essential texts:
- BRS Pathology
- BRS Physiology
- First Aid (started at UCSF!)
- Microbiology Made Ridiculously Simple
2) Other great books:
- Basic Immunology (by Abbas, faculty at UCSF, he made us buy it)
- Neuroanatomy by Blumenfeld
- Neuroanatomy Made Ridiculously Simple
- For detailed biochemistry...Voet & Voet (from Paul)
There is an ocean of review books for pharmacology, gross anatomy, biochemistry, embryology from various series (First Aid has a review of the study resources), but I just relied on First Aid to tell me the important points.
3) Read BRS Pathology with Google Images and Wikipedia nearby...invaluable.
4) The age-old dilemma: Kaplan QBank or USMLE World? A classmate and I bought both qbanks and switched off taking tests on either one...so as someone who has tried both...choose USMLE World because it's cheaper, has more realistic/harder questions, and the testing format looks EXACTLY like the real test with identical buttons, etc.
5) Goljan lectures are entertaining and enlightening and good for those few minutes of the day when you want to be productive without reading.
6) There is a free NBME Practice Test online.
7) Watching "House MD" on DVD as a "break" actually HELPED! Suddenly, tuberous sclerosis doesn't seem so foreign and you get to practice making differentials and seeing weird "zebras" dramatized onscreen.
8) Teaching MS1's (like in MSP) really helps you review material and remember it better.
Overall, I would agree with Craig's evaluation of Step 1...there were more behavioral science and experimental data analysis questions than I expected. Some questions were tricky...some were plain inscrutable (an oxymoron), and others were freebies. :)
Honestly, this might get me tarred and feathered, but I had a lot of fun studying for the boards. It was stimulating to learn new things (there's an ick factor tie between Google imaging STD's and various dermatological lesions) and having unstructured time to eat and play. I slept at 12, woke up at 9, studied for the most of the day in coffee shops, classrooms, or at home...went wine tasting, attended a mnemonics "party," ate meals at restaurants, and it was really only the last 4 days when I started freaking out (ehhh, probably not an endorsement, but there ya go).
Paul and I began studying in earnest around March 6 after formal classes ended, we finished BRS Pathology and Physiology in 9 days and then slowed down when we started reading First Aid in 5 days (read it several times, it's incredibly dense and every word is actually important). Then we started practice questions on Kaplan QBank and USMLE World while reviewing material in various sources.
Overall, I am fairly happy with my score, but of course it's my nature to entertain the nagging feeling that maybe I could have studied harder. Studying was a good experience, however, and I just have to admit that my brain and personality have mellowed with age. :)
Wednesday, April 23, 2008
Monday, April 21, 2008
Inside HEADSSS
Before today, I had never seen the effects of a gunshot wound before, much less a self-inflicted one. I was unsure that the bullet would be easily visualized on the x-ray, but the outline was clearer than a rabies virus capsule. It's true what they say about the identities white opaque things on CT: blood, bone, bullet, or "bontrast" (contrast).
Medicine loves acronyms and mnemonics. Give a poorly spelled and nonsensical acronym that serves as a mnemonic to any medical student and they will write it down and regurgitate it back to you like a highly trained machine. We like crazy sentences and mnemonics full of sexual innuendo. For example, for the brachial plexus, we have "SMI LPM MARMU" and "Randy Travis Drinks Cold Beers." Okay, there was no sexual innuendo. To the untrained eye.
For an assessment of a teenager's psychosocial history, we use HEADSSS (my pet peeve is when they add multiple "invisible" repeats of a letter in the mnemonic), which stands for "Home, Education, Activities, Drugs/Alcohol, Sexual History, Suicidality, and Safety." I underestimated how important HEADSSS can be as a "tool" to cover the basics until my patient was an adolescent with a self-inflicted gunshot wound. Suddenly, the mnemonic was a way to get inside his HEAD(SSS).
Medicine loves acronyms and mnemonics. Give a poorly spelled and nonsensical acronym that serves as a mnemonic to any medical student and they will write it down and regurgitate it back to you like a highly trained machine. We like crazy sentences and mnemonics full of sexual innuendo. For example, for the brachial plexus, we have "SMI LPM MARMU" and "Randy Travis Drinks Cold Beers." Okay, there was no sexual innuendo. To the untrained eye.
For an assessment of a teenager's psychosocial history, we use HEADSSS (my pet peeve is when they add multiple "invisible" repeats of a letter in the mnemonic), which stands for "Home, Education, Activities, Drugs/Alcohol, Sexual History, Suicidality, and Safety." I underestimated how important HEADSSS can be as a "tool" to cover the basics until my patient was an adolescent with a self-inflicted gunshot wound. Suddenly, the mnemonic was a way to get inside his HEAD(SSS).
Tuesday, April 15, 2008
>_<
Today was the first day of Third Year (we're in a 2-week buffer known as Transitional Clerkship) and the rubber has clearly hit the road.
We had class 9-12 pm and then orientation at SFGH (for my group) in the afternoon. Around 10:30 am, the speaker asked if there were any questions and one student asked if we could take a break.
"A break?" the speaker asked blankly, as if to say, what's that?
It was a sign that we've become MS3's...no more touchy feely breaks or administrative coddling! Running down the hallway eating a salad at SFGH today also made me realize that life is going to be a lot more hectic.
Hopefully these 2 weeks will be productive and organizational for me...I've already experienced a few administrative snafu's mostly from being so distracted last month.
Coming back to UCSF for lecture makes me feel like a stranger...the lecture hall was repainted and recarpeted and there were new metal benches outside the nursing building. UCSF does seem to continually change. :)
We had class 9-12 pm and then orientation at SFGH (for my group) in the afternoon. Around 10:30 am, the speaker asked if there were any questions and one student asked if we could take a break.
"A break?" the speaker asked blankly, as if to say, what's that?
It was a sign that we've become MS3's...no more touchy feely breaks or administrative coddling! Running down the hallway eating a salad at SFGH today also made me realize that life is going to be a lot more hectic.
Hopefully these 2 weeks will be productive and organizational for me...I've already experienced a few administrative snafu's mostly from being so distracted last month.
Coming back to UCSF for lecture makes me feel like a stranger...the lecture hall was repainted and recarpeted and there were new metal benches outside the nursing building. UCSF does seem to continually change. :)
Friday, April 11, 2008
Taiwan!
Look, Ma, No Cisplatin!Took Step 1 (gulp) the first week of April and then flew home to LA to take a family trip to Taiwan. The four kids in our family took the coolest picture with a DNA sculpture! Next week begins our orientation for the wards. :)
Tuesday, April 01, 2008
one year ago
Written exactly one year ago today on this blog:
"I woke up at noon today (surprise), worked a little bit on odds and ends before grabbing lunch at the Canvas Gallery with my favorite girl, Kim, around 1:30 p.m.
It was a meal that strangely focused on the theme of endings (at least for me it did)...the Canvas Gallery closing, a long weekend slowly ending, a year gone by in the blink of an eye. Kim (my favorite partner in the metaphysical journey known as life) mentioned how a year is both a long and a short amount of time, and how so many things can happen within the space of 12 months and yet how it's paradoxically not a very long time at all. We talked about daylight savings time and how Kim was upset about losing an hour to talk to her friend in Germany due to daylight savings. It makes me realize that time = love, even more than time = money.
This seemed especially poignant today, because it was the first anniversary of a friend's death, a gifted friend from high school who was preparing to take over my job at Stanford last year before passing away unexpectedly while whitewater rafting in Peru over spring break. Time is a strange beast, and it feels like the most precious thing in the world.
We squander it."
"I woke up at noon today (surprise), worked a little bit on odds and ends before grabbing lunch at the Canvas Gallery with my favorite girl, Kim, around 1:30 p.m.
It was a meal that strangely focused on the theme of endings (at least for me it did)...the Canvas Gallery closing, a long weekend slowly ending, a year gone by in the blink of an eye. Kim (my favorite partner in the metaphysical journey known as life) mentioned how a year is both a long and a short amount of time, and how so many things can happen within the space of 12 months and yet how it's paradoxically not a very long time at all. We talked about daylight savings time and how Kim was upset about losing an hour to talk to her friend in Germany due to daylight savings. It makes me realize that time = love, even more than time = money.
This seemed especially poignant today, because it was the first anniversary of a friend's death, a gifted friend from high school who was preparing to take over my job at Stanford last year before passing away unexpectedly while whitewater rafting in Peru over spring break. Time is a strange beast, and it feels like the most precious thing in the world.
We squander it."
Saturday, March 29, 2008
Psych!
Hilarious article written by next year's Synapse editor, Arul, in honor of our yearly April Fool's issue (called Relapse). For some reason, UCSF has a reputation for being fiercely competitive and intense, but it's actually one of the most touchy-feely medical schools around. We just like to pretend that we're all business -- prickly demeanor on the outside....soft gooey caseating mush on the inside.
Note: this article is entirely fictional.
Grades: As Easy as A, B, C
By Arul Thangavel
Relapse Staff Writer
In a surprising move, UCSF School of Medicine has announced that it will switch from its current Pass/Fail grading system to a more traditional A/B/C grading system at the request of students. Many of the top medical schools in the country have had a Pass/Fail – or the even more friendly Pass/No Pass – system in place for many years now, at least during students’ pre-clinical education, to encourage a spirit of camaraderie and curiosity among students instead of fierce competition. But here at UCSF, many first-year medical students have complained that the current system has not allowed their competitive urges to fully blossom – and as a result, they pushed the administration hard for a change back to what many Deans call “the dark ages.”
Stories of “the dark ages” of medical education, which spanned much of the twentieth century, are severe. Students, graded on a strict curve against their peers, tried whatever they could to get the edge on their classmates, from hiding library books to grabbing group study room cards but not using them, to buying up entire stores of Netter’s Anatomy from the school bookstore to get the famed “restocking advantage” – other students squirmed for thirty days while the consortium of students who bought the multitude of Netter’s sat comfortably by. In one particularly ugly case, a student – not at UCSF – willfully got bitten by a werewolf so he could become a fearsome beast once a month on test day – scaring students and professors out of the room and securing a decided advantage for himself. Only a few students stayed in the room with the seemingly mythical creature, and they had their heads down while it bubbled its Scantron furiously.
First-year medical students at UCSF, though, believe that the pendulum has swung back the other way now. George Hulley, MS-I, laments, “Have you been to one of our small groups? It’s a love-fest. Everyone says, ‘Oh you’re right,’ and then ‘Oh no, you’re right.’ Come on people. You can’t both be right. Man.” Other students complain that tests are far too easy, citing the fact that every student passed the Pulmonary block exam. Michael Tseng, MS-I, suggests, “If everyone in the class is passing, we’re obviously doing something wrong. I have no idea whether I’m better than someone like, say, you, Arul. Without that knowledge, I don’t know if I’m really getting anything out of my medical education. I need to better someone else.” Tseng further displayed his competitive urge by challenging this reporter to a series of mock medical aptitude tests, “right here, right now.” Clearly, UCSF students needed an outlet for these fearful feelings.
UCSF administration says that they tried to provide an outlet to competitive feelings through non-scholarly activities such as intramural sports and extracurricular activities. Even these activities, though, have spiraled into fierce tete-a-tete’s, with one memorable moment involving water balloons, freezers and both Homeless Clinic and Clinica Martin-Baro. Intramural basketball games have ended in utter failure, with each individual student trying to outshine the other on her team, causing massive team losses. In response to these results and strong opinion from students, faculty finally succumbed and allowed grades – even with pluses and minuses – back for next year.
Emily Whichard, MS-I, is excited. “Finally! Now I can show people that I know more than them in a standardized way. Standardized is key. Normally I have to wait until a certain point in a conversation and then chime in the answer from afar. And then you don’t always get the credit. Now I will – the administrators have made the right decision.” Hugo Torres, MS-I, is also gleeful, “I can’t believe how great this is – grades are the best. They make me feel like I’m in high school all over again.”
It remains to be seen how this saga will unfold, but one thing’s for sure – the academic heat has been turned up a notch at UCSF School of Medicine.
Note: this article is entirely fictional.
Grades: As Easy as A, B, C
By Arul Thangavel
Relapse Staff Writer
In a surprising move, UCSF School of Medicine has announced that it will switch from its current Pass/Fail grading system to a more traditional A/B/C grading system at the request of students. Many of the top medical schools in the country have had a Pass/Fail – or the even more friendly Pass/No Pass – system in place for many years now, at least during students’ pre-clinical education, to encourage a spirit of camaraderie and curiosity among students instead of fierce competition. But here at UCSF, many first-year medical students have complained that the current system has not allowed their competitive urges to fully blossom – and as a result, they pushed the administration hard for a change back to what many Deans call “the dark ages.”
Stories of “the dark ages” of medical education, which spanned much of the twentieth century, are severe. Students, graded on a strict curve against their peers, tried whatever they could to get the edge on their classmates, from hiding library books to grabbing group study room cards but not using them, to buying up entire stores of Netter’s Anatomy from the school bookstore to get the famed “restocking advantage” – other students squirmed for thirty days while the consortium of students who bought the multitude of Netter’s sat comfortably by. In one particularly ugly case, a student – not at UCSF – willfully got bitten by a werewolf so he could become a fearsome beast once a month on test day – scaring students and professors out of the room and securing a decided advantage for himself. Only a few students stayed in the room with the seemingly mythical creature, and they had their heads down while it bubbled its Scantron furiously.
First-year medical students at UCSF, though, believe that the pendulum has swung back the other way now. George Hulley, MS-I, laments, “Have you been to one of our small groups? It’s a love-fest. Everyone says, ‘Oh you’re right,’ and then ‘Oh no, you’re right.’ Come on people. You can’t both be right. Man.” Other students complain that tests are far too easy, citing the fact that every student passed the Pulmonary block exam. Michael Tseng, MS-I, suggests, “If everyone in the class is passing, we’re obviously doing something wrong. I have no idea whether I’m better than someone like, say, you, Arul. Without that knowledge, I don’t know if I’m really getting anything out of my medical education. I need to better someone else.” Tseng further displayed his competitive urge by challenging this reporter to a series of mock medical aptitude tests, “right here, right now.” Clearly, UCSF students needed an outlet for these fearful feelings.
UCSF administration says that they tried to provide an outlet to competitive feelings through non-scholarly activities such as intramural sports and extracurricular activities. Even these activities, though, have spiraled into fierce tete-a-tete’s, with one memorable moment involving water balloons, freezers and both Homeless Clinic and Clinica Martin-Baro. Intramural basketball games have ended in utter failure, with each individual student trying to outshine the other on her team, causing massive team losses. In response to these results and strong opinion from students, faculty finally succumbed and allowed grades – even with pluses and minuses – back for next year.
Emily Whichard, MS-I, is excited. “Finally! Now I can show people that I know more than them in a standardized way. Standardized is key. Normally I have to wait until a certain point in a conversation and then chime in the answer from afar. And then you don’t always get the credit. Now I will – the administrators have made the right decision.” Hugo Torres, MS-I, is also gleeful, “I can’t believe how great this is – grades are the best. They make me feel like I’m in high school all over again.”
It remains to be seen how this saga will unfold, but one thing’s for sure – the academic heat has been turned up a notch at UCSF School of Medicine.
Wednesday, March 26, 2008
Amusing Quote
Lily Tomlin - "The trouble with the rat race is that even if you win, you're still a rat."
Tuesday, March 25, 2008
it's sort of funny...after the hundredth time
P: "Leigh's disease
I have no idea what that is
it's not in first aid or BRS path
the explanation starts off w/.. "this disease is so rare that most physicians will never see it ever in their life"
"some sort of mitochondrial deficiency.. present w/ ataxia and other neural signs"
...
I hate them."
I have no idea what that is
it's not in first aid or BRS path
the explanation starts off w/.. "this disease is so rare that most physicians will never see it ever in their life"
"some sort of mitochondrial deficiency.. present w/ ataxia and other neural signs"
...
I hate them."
Sunday, March 23, 2008
in retrospect
My 24th birthday was really special, even though UCSF conspires to make every birthday slightly hectic (last year: M&N exam, this year: boards, next year: rotations, 4th year: Match Day).
Studying for the boards has helped me understand the medical conditions of the patients whom we have interviewed in the hospital for the past 1.5 years. In particular, I just wanted to jot something down right now about a woman in the neurology wards who I now realize had one of the defining illnesses of AIDS: HIV encephalitis. At the time, I didn't understand what that could be, or that she even exhibited signs of it. Talking to her about her life (she was in her 30s and a professional dog walker), she seemed normal but now I realize how much patients can preserve social graces in the face of debilitating mental conditions. She could talk about her life and her background, but she couldn't name simple objects and often mixed them up with similar sounding words. In retrospect, she was so young, and she was in bad shape...but she said to me, "Want to know something? HIV hasn't changed much, I've had a good life."
And for some reason right now, I want to believe her.
Studying for the boards has helped me understand the medical conditions of the patients whom we have interviewed in the hospital for the past 1.5 years. In particular, I just wanted to jot something down right now about a woman in the neurology wards who I now realize had one of the defining illnesses of AIDS: HIV encephalitis. At the time, I didn't understand what that could be, or that she even exhibited signs of it. Talking to her about her life (she was in her 30s and a professional dog walker), she seemed normal but now I realize how much patients can preserve social graces in the face of debilitating mental conditions. She could talk about her life and her background, but she couldn't name simple objects and often mixed them up with similar sounding words. In retrospect, she was so young, and she was in bad shape...but she said to me, "Want to know something? HIV hasn't changed much, I've had a good life."
And for some reason right now, I want to believe her.
Friday, March 21, 2008
What?
Lost my hearing and my voice at an awesome 80s cover band concert. It's all part of the normal aging process. So happy! :)
If medical students studying for the boards start talking about bizarre illnesses...just yell out the safety word: "PEANUT BUTTER AND JELLY SANDWICH!!!" To get them to stop.
If medical students studying for the boards start talking about bizarre illnesses...just yell out the safety word: "PEANUT BUTTER AND JELLY SANDWICH!!!" To get them to stop.
Thursday, March 20, 2008
Caffeine Is the New Coke
Think about coffee and then think about the criteria for substance dependence (from First Aid 2008):
1. Tolerance - need more to achieve same effect
2. Withdrawal
3. Substance taken in larger amounts of over longer time than desired
4. Persistent desire or attempts to cut down
5. Significant energy spent obtaining, using, or recovering from substance
6. Important social, occupational, or recreational activities reduced because of substance use
7. Continued use in spite of knowing the problems that it causes
Creepy!
1. Tolerance - need more to achieve same effect
2. Withdrawal
3. Substance taken in larger amounts of over longer time than desired
4. Persistent desire or attempts to cut down
5. Significant energy spent obtaining, using, or recovering from substance
6. Important social, occupational, or recreational activities reduced because of substance use
7. Continued use in spite of knowing the problems that it causes
Creepy!
Monday, March 17, 2008
Signs of Mental Decline
The first sign of dementia is losing track of your surroundings...I am definitely not alert & oriented x 3. In fact, I'm not even sure what day it is, but it doesn't trouble me too much. It's funny how they say boards studying will fry your brain...I've definitely lost my short-term memory (hello, Alzheimer's) and I even think that I may have Broca's aphasia at this point....finding words is SO DIFFICULT. I can't speak normally anymore....it all comes out in short words like..."need...eat...ribosome?"
Friday, March 14, 2008
The Effects of Boards Studying
S: "Can you come up with a mnemonic for uremia (kidney failure)?
Signs of uremia:
Azotemia
Acidosis
Hyperkalemia
Hypocalcemia
Anemia
Hypertension
....
Pericarditis"
P: "Hey, how about 'HAHAHA...pericarditis'?"
Signs of uremia:
Azotemia
Acidosis
Hyperkalemia
Hypocalcemia
Anemia
Hypertension
....
Pericarditis"
P: "Hey, how about 'HAHAHA...pericarditis'?"
Sunday, March 09, 2008
Boards Boot Camp
UCSF has given us 4 weeks to take the USLME Step 1. I am liking the unstructured time to study, but am currently starting to get worried and quickly losing track of time (what day is it? what time is it? when did I last eat?)...and it's only been day 2 post-life cycle final.
Will send periodic updates from the black hole that is boards studying.
Will send periodic updates from the black hole that is boards studying.
Wednesday, March 05, 2008
Seminal Events
Yesterday: I ate lobster for the first time in my life (if you don't count the allergic reaction when I was 2 years old). Thanks to Paul for introducing crustaceans and clams into my diet.
Today: Studied in the sunshine for 4 hours.
Tomorrow: Last medical school test.
Today: Studied in the sunshine for 4 hours.
Tomorrow: Last medical school test.
Tuesday, March 04, 2008
Last Day of Class
Today was our last day of formal lecture at UCSF...how quickly the time flies by! After the Life Cycle exam on Thursday, we will be on our own studying for the USMLE Step 1.
Today our small group had a small celebration with mimosas and home-baked muffins (courtesy of Char who woke up early to bake them) and peppermint bark (courtesy of DSL). After a fun patient interview with an elder, our class celebrated our transition from the classroom into the boards and wards with a raffle, a few words from the interim Dean, and a slideshow made by an MS4.
Today our small group had a small celebration with mimosas and home-baked muffins (courtesy of Char who woke up early to bake them) and peppermint bark (courtesy of DSL). After a fun patient interview with an elder, our class celebrated our transition from the classroom into the boards and wards with a raffle, a few words from the interim Dean, and a slideshow made by an MS4.
Tuesday, February 26, 2008
MSP, I Love Thee
The most valuable experience this year has been teaching for the Medical Scholars Program (MSP) at UCSF. MSP is a program consisting of 16 MS2's who run 30 minute review sessions of anatomy, cardiovascular, respiratory, and renal material to the MS1's from September through February 2008.
Since the MS1's are currently applying for MSP, this is a great opportunity for me to list reasons to apply for MSP:
1) MSP gives you lots of practice about how to communicate lessons in different ways (visual, audio, kinetic) to your peers
2) You learn how to answer questions or handle questions that you don't know the answer to (very very valuable on wards I would imagine with both patients and attendings)
3) MSP is a lot of fun and the people are really energetic
4) There's a great MSP tradition and you feel like you're part of something special :)
5) GREAT review for boards, you relearn important things, the best preparation is teaching and everything you do actually helps you in the end
6) you earn a small stipend for being an MSP leader
The only drawback is that MSP does take up a lot of time (especially preparation) depending on the type of person you are. Some people take a few hours, while some people take days preparing. It was a little frustrating in the fall, because i was studying for I3, prologue, and taking a grad class in biostatistics at the same time, so it was like 2/3 of my studying wasn't even going towards "medical school." I did feel sometimes like i was studying for first year all over again but now the reviews are a lot less painful so i think it was worth it.
What do MSP coordinators look for? They want enthusiasm and great communicators. :)
Since the MS1's are currently applying for MSP, this is a great opportunity for me to list reasons to apply for MSP:
1) MSP gives you lots of practice about how to communicate lessons in different ways (visual, audio, kinetic) to your peers
2) You learn how to answer questions or handle questions that you don't know the answer to (very very valuable on wards I would imagine with both patients and attendings)
3) MSP is a lot of fun and the people are really energetic
4) There's a great MSP tradition and you feel like you're part of something special :)
5) GREAT review for boards, you relearn important things, the best preparation is teaching and everything you do actually helps you in the end
6) you earn a small stipend for being an MSP leader
The only drawback is that MSP does take up a lot of time (especially preparation) depending on the type of person you are. Some people take a few hours, while some people take days preparing. It was a little frustrating in the fall, because i was studying for I3, prologue, and taking a grad class in biostatistics at the same time, so it was like 2/3 of my studying wasn't even going towards "medical school." I did feel sometimes like i was studying for first year all over again but now the reviews are a lot less painful so i think it was worth it.
What do MSP coordinators look for? They want enthusiasm and great communicators. :)
Core Lottery
Our Core Lottery list was due this morning at 8 a.m. For great coverage of the lottery, please see Craig's blog on the right sidebar. I regret not spending more time obsessing about my rotation preferences, but suspect that it would have been sort of pointless. Results are due March 7 (after our Life Cycle final on March 6). It's sort of an interesting process...like putting all your preferences into a magical Sorting Hat and seeing what comes out.
Sunday, February 24, 2008
OSCE
The MS2's are spending this weekend taking the OSCE (Objective Structured Clinical Examination...just know that it's pronounced "oskey" and it means that we have a clinical skills exam). We need to pass the 4-hour OSCE to participate in our core rotations next year.
The OSCE was pretty enjoyable and fast-faced...we ran around to 6 stations with different scenarios and standardized patients. Some stations focused on a particular organ system (patient with lung problems, abdominal pain, sinus infection, actual neurological findings!) and others were focused on patient-doctor communication (delivering serious news, trying to explore sensitive issues). My only critique is that it was a little frustrating trying to decipher which patient tidbits we were supposed to notice and explore and which we should ignore because we are still practicing and playing an elaborate game of "make-believe." For example, a patient who complains of "shortness of breath," but who sits there calmly with a RR of 10 and lungs CTA. Or a standardized patient (SP) who glances at the clock twice and expects me to ask her why she seemed anxious. The OSCE can easily devolve into an elaborate game of "guess what I want you to do."
Overall, however, the OSCE was really valuable and we had to pass it to do clinical rotations next year. I am really glad that we did the OSCE with our Foundations of Patient Care (FPC) groups, because it was actually really comforting to see Carson, Rodney, Miguel, and Jason (my "POD," we are whales or peas) there. We're like a little family. :)
Today we had our final FPC dinner at Park Chow and ate ginger cake!
The OSCE was pretty enjoyable and fast-faced...we ran around to 6 stations with different scenarios and standardized patients. Some stations focused on a particular organ system (patient with lung problems, abdominal pain, sinus infection, actual neurological findings!) and others were focused on patient-doctor communication (delivering serious news, trying to explore sensitive issues). My only critique is that it was a little frustrating trying to decipher which patient tidbits we were supposed to notice and explore and which we should ignore because we are still practicing and playing an elaborate game of "make-believe." For example, a patient who complains of "shortness of breath," but who sits there calmly with a RR of 10 and lungs CTA. Or a standardized patient (SP) who glances at the clock twice and expects me to ask her why she seemed anxious. The OSCE can easily devolve into an elaborate game of "guess what I want you to do."
Overall, however, the OSCE was really valuable and we had to pass it to do clinical rotations next year. I am really glad that we did the OSCE with our Foundations of Patient Care (FPC) groups, because it was actually really comforting to see Carson, Rodney, Miguel, and Jason (my "POD," we are whales or peas) there. We're like a little family. :)
Today we had our final FPC dinner at Park Chow and ate ginger cake!
Friday, February 22, 2008
Mittelschmerz
Some women experience pain during ovulation, which someone coined as "mittelschmerz." It is quite possibly one of the quirkiest terms and definitions in medicine. According to Wiki, the term is German for "middle pain," and I would have to say that life is definitely in that slightly uncomfortable "in-between" stage right now.
Last year, I never realized how the MS2's were suffering in semi-silence -- crunched with Life Cycle, finishing up activities, trying to study for boards a month away, and trying to decode the Core rotation lottery for next Tuesday. Ahh, so much to do right now and I still haven't worked on a manuscript that I wanted to draft by last December. :( Mittelschmerz.
*** On March 6, Synapse is publishing a Women's Issue, so please contribute any articles, photos, or women-inspired poetry and artwork to synapse@ucsf.edu by March 3, 2008. THANKS! :)
Last year, I never realized how the MS2's were suffering in semi-silence -- crunched with Life Cycle, finishing up activities, trying to study for boards a month away, and trying to decode the Core rotation lottery for next Tuesday. Ahh, so much to do right now and I still haven't worked on a manuscript that I wanted to draft by last December. :( Mittelschmerz.
*** On March 6, Synapse is publishing a Women's Issue, so please contribute any articles, photos, or women-inspired poetry and artwork to synapse@ucsf.edu by March 3, 2008. THANKS! :)
Wednesday, February 20, 2008
Lunar Eclipse
From the SF Chronicle (photo by Fredric Larson)We drove to a small hill near Twin Peaks to see the lunar eclipse tonight around 7 p.m. The next lunar eclipse will be in December 2010, and Paul joked that at least one of us would be doctors by then. Stepping out of the car, the eclipse had already happened and all we could see was a tiny round wisp of cloud that we presumed was the lunar eclipse...but perhaps it was an artifact. In the dark, we climbed a hill and found a group of strangers staring into a navy blue sky without a moon in sight, the city of San Francisco lying underneath our feet lit up like a giant circuit board and the "sun" and "moon" visible on either side of the bay.
A lunar eclipse, by definition, is the partial disappearance of something. And when the moon is totally eclipsed, we found that there is actually not that much to see. So we waited for about 30 minutes for the moon to reappear, standing on the hill in the darkness. Jon asked how far away the earth was from the sun, what the tilt of the earth's axis was, and how many miles it would be to the center of the earth. Paul and Jon made a few speculations to kill the time, and Collin teased us with a riddle about wrapping a string tightly around earth and asking us how far we could pull the string from the ground if the string were lengthened by 1 inch.
I tried to remember some poetry to recite or talk about, but my thoughts were as wispy as the clouds (cirrus? asked Jon). All I could remember was Romeo's "it is the East, and Juliet is the sun," and a poem by Langston Huges about the sharp crook of the moon, "Dover Beach," and most of all, a poem called "Sad Steps" by Phil Larkin...which itself was a reference to Sidney's "Astrophil and Stella." But maybe "Sad Steps" was more appropriate than I realized, since it is after all a poem about the passage of time, reverence tinged with irreverence, and most of all an awareness that we shall all grow old together with other strangers in the darkness.
Sad Steps
Groping back to bed after a piss
I part thick curtains, and am startled by
The rapid clouds, the moon's cleanliness.
I part thick curtains, and am startled by
The rapid clouds, the moon's cleanliness.
Four o'clock: wedge-shadowed gardens lie
Under a cavernous, a wind-picked sky.
There's something laughable about this,
Under a cavernous, a wind-picked sky.
There's something laughable about this,
The way the moon dashes through clouds that blow
Loosely as cannon-smoke to stand apart
(Stone-coloured light sharpening the roofs below)
Loosely as cannon-smoke to stand apart
(Stone-coloured light sharpening the roofs below)
High and preposterous and separate -
Lozenge of love! Medallion of art!
O wolves of memory! Immensements! No,
Lozenge of love! Medallion of art!
O wolves of memory! Immensements! No,
One shivers slightly, looking up there.
The hardness and the brightness and the plain
Far-reaching singleness of that wide stare
The hardness and the brightness and the plain
Far-reaching singleness of that wide stare
Is a reminder of the strength and pain
Of being young; that it can't come again,
But is for others undiminished somewhere.
Of being young; that it can't come again,
But is for others undiminished somewhere.
- Philip Larkin
Around 7:50 p.m., the eclipse ended and the moon returned faintly, shining on its rounded edge like a pure white crescent wrapped in clouds and city light.
Thursday, February 14, 2008
Happy Valentine's Day
From today's special Valentine's Synapse:
Top 10 Things to Do if You’re Single on Valentine’s Day
By Irene Kang and Stephanie Chang
Staff Writers
Valentine’s Day, known as Singles Awareness Day to some, can be a day in which a sickening amount of Hallmark cards, chocolate, red roses and overpriced dinners are bought. With more and more people revolting against the commercialized holiday, Valentine’s Day can be made into a reason to celebrate singledom; there are more and more things to do for a good time. Here are some of the best ways to spend February 14 if you’re lucky enough to be single:
1. Go to the gym. –What?!?! Get your endorphin fix…and if that cute guy or gal is also at the gym tonight, you’ll know he or she is probably available and single.
2. Channel Cupid and shoot stuff! Even an ounce of pent-up frustration won’t be able to stand up against some therapeutic paint-balling. Gather a group of friends and shoot away. Any couples silly enough to show up to the field will have it coming.
3. Watch a zombie movie because nothing says Valentine’s Day better than “Auuuuugh!!!” Actually, there are several movies opening on February the 14th. Jumper, an action flick by the makers of The Bourne Identity, promises to get your adrenaline running while Definitely, Maybe, a romantic comedy starring Ryan Reynolds, seems to be appropriate if you are in that sort of mood.
4. Un-Valentine’s Day clubbing is the new trend. Get awesome deals and even complimentary chocolates at your favorite clubs and bars. For example, the Dirty Martini has $2 drinks on Thursdays. Chances are other fun-loving singles will also be out and about this evening. http://www.sfstation.com/valentines/ has a list of Anti-Valentine’s Day parties for the night.
5. While couples are fretting over getting into that four-star restaurant for a prix-fixe meal, you can rest assured that your wallet will survive the day. Go somewhere unpretentious with friends, so you won’t be surrounded by couples. Another option is to invite friends over for dinner.
6. Make V-Day into Me day. Everyone needs love, and maybe you’re overdue.
Setting aside time for yourself is always a good idea and particularly appropriate on Valentine’s Day. Whether you’re single or not, this day is meant to be enjoyed, so go out and get that massage or eat your favorite flavor of ice cream.
7. The UCSF production of The Vagina Monologues is playing tonight. It makes for an awesome Valentine’s evening whether you’re with someone or not.
The Vagina Monologues will be Thursday, Feb. 14th and Friday, Feb. 15th at 7pm in Toland Hall. Tickets are $8.
8. No matter who you are, you already have a Valentine. Show your appreciation to someone you love whether it’s sending flowers to your mom, calling up your best friend from college or knitting a sweater for your Chihuahua.
9. Any thoughts of Valentine’s Day should be eclipsed by the fact that this weekend is President’s Day weekend.
That means that you can make plans for an awesome three-day weekend.
It’s the perfect time of year for Tahoe, and you can pack it in and get several days’ worth of fun on the slopes.
10. At the end of the day many of us are still students. We may have class or have to teach an elective. Does your Valentine’s Day look like this? Midterm Exam, Physical Exam Review at the Clinical Skills Center, MSP teaching session from 6-8 p.m. It’s okay… this too is a meaningful way to spend the day. Really, Stephanie. It is.
Irene Kang and Stephanie Chang are second-year medical students.
Top 10 Things to Do if You’re Single on Valentine’s Day
By Irene Kang and Stephanie Chang
Staff Writers
Valentine’s Day, known as Singles Awareness Day to some, can be a day in which a sickening amount of Hallmark cards, chocolate, red roses and overpriced dinners are bought. With more and more people revolting against the commercialized holiday, Valentine’s Day can be made into a reason to celebrate singledom; there are more and more things to do for a good time. Here are some of the best ways to spend February 14 if you’re lucky enough to be single:
1. Go to the gym. –What?!?! Get your endorphin fix…and if that cute guy or gal is also at the gym tonight, you’ll know he or she is probably available and single.
2. Channel Cupid and shoot stuff! Even an ounce of pent-up frustration won’t be able to stand up against some therapeutic paint-balling. Gather a group of friends and shoot away. Any couples silly enough to show up to the field will have it coming.
3. Watch a zombie movie because nothing says Valentine’s Day better than “Auuuuugh!!!” Actually, there are several movies opening on February the 14th. Jumper, an action flick by the makers of The Bourne Identity, promises to get your adrenaline running while Definitely, Maybe, a romantic comedy starring Ryan Reynolds, seems to be appropriate if you are in that sort of mood.
4. Un-Valentine’s Day clubbing is the new trend. Get awesome deals and even complimentary chocolates at your favorite clubs and bars. For example, the Dirty Martini has $2 drinks on Thursdays. Chances are other fun-loving singles will also be out and about this evening. http://www.sfstation.com/valentines/ has a list of Anti-Valentine’s Day parties for the night.
5. While couples are fretting over getting into that four-star restaurant for a prix-fixe meal, you can rest assured that your wallet will survive the day. Go somewhere unpretentious with friends, so you won’t be surrounded by couples. Another option is to invite friends over for dinner.
6. Make V-Day into Me day. Everyone needs love, and maybe you’re overdue.
Setting aside time for yourself is always a good idea and particularly appropriate on Valentine’s Day. Whether you’re single or not, this day is meant to be enjoyed, so go out and get that massage or eat your favorite flavor of ice cream.
7. The UCSF production of The Vagina Monologues is playing tonight. It makes for an awesome Valentine’s evening whether you’re with someone or not.
The Vagina Monologues will be Thursday, Feb. 14th and Friday, Feb. 15th at 7pm in Toland Hall. Tickets are $8.
8. No matter who you are, you already have a Valentine. Show your appreciation to someone you love whether it’s sending flowers to your mom, calling up your best friend from college or knitting a sweater for your Chihuahua.
9. Any thoughts of Valentine’s Day should be eclipsed by the fact that this weekend is President’s Day weekend.
That means that you can make plans for an awesome three-day weekend.
It’s the perfect time of year for Tahoe, and you can pack it in and get several days’ worth of fun on the slopes.
10. At the end of the day many of us are still students. We may have class or have to teach an elective. Does your Valentine’s Day look like this? Midterm Exam, Physical Exam Review at the Clinical Skills Center, MSP teaching session from 6-8 p.m. It’s okay… this too is a meaningful way to spend the day. Really, Stephanie. It is.
Irene Kang and Stephanie Chang are second-year medical students.
Monday, February 11, 2008
Synapse Valentine's Dedications
SUBMIT A VALENTINE'S DEDICATION TO SYNAPSE
Remember those elementary school days when you wrote Valentine messages to your friends in the school newspaper? This year, Synapse is hitting the stands on Thursday, February 14th, and we want to publish YOUR special Valentine's wishes for FREE.
Send a short message (50 word limit) to synapse@ucsf.edu by the deadline on Tuesday, February 12th, by 12 pm. Look for your dedications on Valentine's Day, February 14th!!
Disclaimer: Synapse does not guarantee that all dedications will be printed as requested. All dedications submitted will be used at the discretion of Synapse.
Remember those elementary school days when you wrote Valentine messages to your friends in the school newspaper? This year, Synapse is hitting the stands on Thursday, February 14th, and we want to publish YOUR special Valentine's wishes for FREE.
Send a short message (50 word limit) to synapse@ucsf.edu by the deadline on Tuesday, February 12th, by 12 pm. Look for your dedications on Valentine's Day, February 14th!!
Disclaimer: Synapse does not guarantee that all dedications will be printed as requested. All dedications submitted will be used at the discretion of Synapse.
Sunday, February 10, 2008
Lantern and Rope Riddles
A posting over the summer about riddles was warmly received by a few people who talked to me, so I am posting another set of riddles given to me by Paul, who passes them out like hard candies. Answers are written in light blue, so please highlight the text with your mouse to see the text more clearly.
LANTERN RIDDLE
A great pharoah of Egypt wanted to send 100 lanterns down the Nile River, and he set 100 servants to do a certain task. The lanterns would be floated down, and the first servant would light each one. The second servant would extinguish the 2nd, 4th, 6th (every even-numbered) lantern, while a third servant would find a lantern either "on"/"off" and then extinguish/relight every 3rd lantern. The fourth servant would look at every 4th lantern and also extinguish/relight the lantern depending on its present state...and so on until the 100th servant either extinguishes or relights the 100th lantern.
By the end of the ceremony, which lanterns are lit and which ones are extinguished?
ANSWER: There's an easy way and a hard way. The hard way is to make a chart and map out the pattern of the first 10 or so lanterns as they progress down the Nile. After the 10th servant has made his move, none of the succeedingly servants will touch the first 10 lanterns and you can determine their final state. You will find that lanterns 1, 4, and 9 will remain lit...and then find since 1+3 = 4, and 4+5 = 9, then why not add 9+7 = 16? By using this pattern, you will find that lanterns 1, 4, 9, 16, and 25 will remain lit. What is the pattern? All the lanterns are squares!
"But WHY?" you ask. The easy solution is to realize that, say, for lantern 20, that it will be touched by servants 1, 2, 4, 5, 10, and 20 (factors of 20, as Paul reminds), which is an even number of servants, and hence the lantern will be ultimately extinguished. However, for lantern 25, which is a square, the lantern will be touched by servants 1, 5, and 25, which will always be an ODD number since squares will always have an odd number of factors -- and thus lantern 25 will remain lit. Therefore, by the end of the ceremony, only lanterns which are square numbers will be lit!
PAUL'S TRICKY LANTERN RIDDLE
Paul made up this variation of the lantern riddle himself in half a second.
Pretend the same scenario of 100 lanterns and 100 servants. The first servant lights each lantern as usual, but this time EACH SERVANT will meddle with the first lantern and continue his pattern. So the 2nd servant would extinguish lamps 1, 3, 5, etc. The third servant would light/extinguish lamps 1, 4, 7, etc. And the fourth servant would light/extinguish lamps 1, 5, 9, etc.
By the end of the ceremony, which lanterns are lit and which ones are extinguished?
ANSWER: The hard way is to make another chart and determine which lanterns are lit and extinguished, as before, which will allow you to find that lanterns 2, 5, and 10 will be lit by the end of the ceremony. This pattern is square numbers + 1, so all lanterns that are a square number + 1 will be lit by the end.
BUT WHY? Since every servant touches the first lantern, regard the first lantern as LANTERN zero. The pattern of lighting has been shifted over 1 position, so that it will always be square+1.
ROPE RIDDLE
A semi-easier question supposedly asked by interviewers at JP Morgan. Pretend that you have TWO ropes which do NOT burn at a constant rate throughout the rope, but are cut to ensure that they will burn for exactly 1 hour each. Using only these two ropes, how do you measure out 45 minutes?
ANSWER: Burning the rope at one end will measure out 1 hour, but burning a rope at both ends will measure out 30 minutes, despite the variable burn rates. Start by lighting Rope 1 at one end and Rope 2 at both ends. When Rope 2 burns out, 30 minutes have elapsed -- and then quickly light the other end of Rope 1 so that you will get half of the remaining 30 minutes. Since 30 + 15 = 45, you will measure out 45 minutes. :)
LANTERN RIDDLE
A great pharoah of Egypt wanted to send 100 lanterns down the Nile River, and he set 100 servants to do a certain task. The lanterns would be floated down, and the first servant would light each one. The second servant would extinguish the 2nd, 4th, 6th (every even-numbered) lantern, while a third servant would find a lantern either "on"/"off" and then extinguish/relight every 3rd lantern. The fourth servant would look at every 4th lantern and also extinguish/relight the lantern depending on its present state...and so on until the 100th servant either extinguishes or relights the 100th lantern.
By the end of the ceremony, which lanterns are lit and which ones are extinguished?
ANSWER: There's an easy way and a hard way. The hard way is to make a chart and map out the pattern of the first 10 or so lanterns as they progress down the Nile. After the 10th servant has made his move, none of the succeedingly servants will touch the first 10 lanterns and you can determine their final state. You will find that lanterns 1, 4, and 9 will remain lit...and then find since 1+3 = 4, and 4+5 = 9, then why not add 9+7 = 16? By using this pattern, you will find that lanterns 1, 4, 9, 16, and 25 will remain lit. What is the pattern? All the lanterns are squares!
"But WHY?" you ask. The easy solution is to realize that, say, for lantern 20, that it will be touched by servants 1, 2, 4, 5, 10, and 20 (factors of 20, as Paul reminds), which is an even number of servants, and hence the lantern will be ultimately extinguished. However, for lantern 25, which is a square, the lantern will be touched by servants 1, 5, and 25, which will always be an ODD number since squares will always have an odd number of factors -- and thus lantern 25 will remain lit. Therefore, by the end of the ceremony, only lanterns which are square numbers will be lit!
PAUL'S TRICKY LANTERN RIDDLE
Paul made up this variation of the lantern riddle himself in half a second.
Pretend the same scenario of 100 lanterns and 100 servants. The first servant lights each lantern as usual, but this time EACH SERVANT will meddle with the first lantern and continue his pattern. So the 2nd servant would extinguish lamps 1, 3, 5, etc. The third servant would light/extinguish lamps 1, 4, 7, etc. And the fourth servant would light/extinguish lamps 1, 5, 9, etc.
By the end of the ceremony, which lanterns are lit and which ones are extinguished?
ANSWER: The hard way is to make another chart and determine which lanterns are lit and extinguished, as before, which will allow you to find that lanterns 2, 5, and 10 will be lit by the end of the ceremony. This pattern is square numbers + 1, so all lanterns that are a square number + 1 will be lit by the end.
BUT WHY? Since every servant touches the first lantern, regard the first lantern as LANTERN zero. The pattern of lighting has been shifted over 1 position, so that it will always be square+1.
ROPE RIDDLE
A semi-easier question supposedly asked by interviewers at JP Morgan. Pretend that you have TWO ropes which do NOT burn at a constant rate throughout the rope, but are cut to ensure that they will burn for exactly 1 hour each. Using only these two ropes, how do you measure out 45 minutes?
ANSWER: Burning the rope at one end will measure out 1 hour, but burning a rope at both ends will measure out 30 minutes, despite the variable burn rates. Start by lighting Rope 1 at one end and Rope 2 at both ends. When Rope 2 burns out, 30 minutes have elapsed -- and then quickly light the other end of Rope 1 so that you will get half of the remaining 30 minutes. Since 30 + 15 = 45, you will measure out 45 minutes. :)
Saturday, February 09, 2008
Imperfections
Matthew in Sacramento, State Capitol, February 2008My brother Matthew visited the State Capitol this weekend for a high school competition, and the group found the infamous misplaced tile in the floor that generations of Arcadia High students have been excited about for decades.
Legend has it that the architect of the capitol building placed this tile incorrectly himself, to leave his personal mark on the building, yet it seems a little excessive since he designed the entire building (!).
The photo has me thinking about leaving behind legacies and the nature of imperfections. My favorite emotional philosopher, Kim, has often talked about the beauty of slight imperfections or maybe even gross imperfections -- and how they make people, places, and objects even more treasured, unique, and yea, vulnerable.
The quirky misplaced tile sets my thoughts in motion, because it is so different -- a misfit of geometric patterning. Why does it draw the eye to itself so irresistibly and why do I endow it with so much personality and vulnerability? After years of talking with Kim and college friends as we struggled and grew to love our own imperfections, there remains a continuous conflict between loving others for their flaws and yet not forgiving them in ourselves.
I love those imperfections that make people human -- the bald spots, the surgical scars, the absurdly long toe, or a hint of assymetry -- and I love those invisible imperfections that make people real -- a heightened sensitivity, a fiery temper, a secret sadness. It seems to me that we are ultimately composed entirely of irregularities and idiosyncracies like elaborate variations on the basic geometric pattern of humanity. By these unique flaws, we leave our mark on earth and on others.
Thursday, February 07, 2008
What a Hoot!
My little MS1 sib, Scott, left me a furry present in my mailbox...an owl finger puppet! I love it!
My pediatric preceptor gave me a bright butterly finger puppet...my collection is growing!
I am 23, by the way. :)
My pediatric preceptor gave me a bright butterly finger puppet...my collection is growing!
I am 23, by the way. :)
Happy Chinese New Year
Year of the Rat - Rose Parade 2008Paul hosted a hot pot dinner tonight with 12 guests in honor of Chinese New Year's Eve. It was lovely and wonderful and there was a cheery flame in the fireplace. Sat down and ate continuously for 2-3 hours. :) Thank you so much, Paul!
The night before Chinese New Year has new significance since my grandmother passed away last year on new year's eve. My grandmother took new year's seriously; it was the most important time of year for her. She would buy candy and decorations and make little pyramids of oranges and kumquats from our backyard. Before she went to bed the night she died, she set out 4 red envelopes on her dresser to give to the kids in our family so that they would be within easy reach the next morning when she would give us her little benediction.
We found those envelopes after she died, and I never told anyone this -- it has been my secret for a year -- but I took my own red envelope and the 2 red candies that she had placed on top and carried them with me back to San Francisco. The red envelope has been sitting in my bookshelf for almost a year now, and I have never opened it.
Wednesday, February 06, 2008
I Am Not Hitting on You
Anyone want to practice the physical exam for the OSCE?
Requirement: Must be alive.
Requirement: Must be alive.
Tuesday, February 05, 2008
Two Fake Pinkberries = Heaven
Oh. My. Gosh.
Okay, I know that Pinkberry is overrated and that sugar-free, fat-free, food-free yogurt shouldn't be so addictive, but there's just something about Pinkberry that makes me buy into the hype. What also intrigues me is the phenomenon of so many FAKE Pinkberries -- so many unashamedly brash knock-offs of the cute, simple, yogurt enterprise that offer the same menu and decorations.
Yesterday, I tried the fake Pinkberry known as Jubili on Fillmore St. and it was actually not that great. The yogurt is more bland and it just didn't have the same addictive quality.
TODAY, boy, I am so excited, Paul and I stumbled upon a FAKE PINKBERRY on IRVING. ST. That's right, UCSF, there's a FAKE PINKBERRY ON IRVING ST. and you READ IT HERE FIRST! The store is called Tuttimelon and it just opened near the corner of 23rd Ave. and Irving St. last Saturday. They are having a special discount of 99 cents for a small, original yogurt, but toppings cost extra. The yogurt was better than Jubili and closer to that tart, sour cream-like taste of Pinkberry, but still not creamy enough.
By the way, the Synapse FOOD ISSUE is coming out this Thursday and it's a fantastic 20-page issue of all foodie goodness. Seriously, I am so stoked.
Jubili
1515 Fillmore Street, San Francisco, CA 94115
Tuttimelon
2150 Irving Street, San Francisco, CA
Okay, I know that Pinkberry is overrated and that sugar-free, fat-free, food-free yogurt shouldn't be so addictive, but there's just something about Pinkberry that makes me buy into the hype. What also intrigues me is the phenomenon of so many FAKE Pinkberries -- so many unashamedly brash knock-offs of the cute, simple, yogurt enterprise that offer the same menu and decorations.
Yesterday, I tried the fake Pinkberry known as Jubili on Fillmore St. and it was actually not that great. The yogurt is more bland and it just didn't have the same addictive quality.
TODAY, boy, I am so excited, Paul and I stumbled upon a FAKE PINKBERRY on IRVING. ST. That's right, UCSF, there's a FAKE PINKBERRY ON IRVING ST. and you READ IT HERE FIRST! The store is called Tuttimelon and it just opened near the corner of 23rd Ave. and Irving St. last Saturday. They are having a special discount of 99 cents for a small, original yogurt, but toppings cost extra. The yogurt was better than Jubili and closer to that tart, sour cream-like taste of Pinkberry, but still not creamy enough.
By the way, the Synapse FOOD ISSUE is coming out this Thursday and it's a fantastic 20-page issue of all foodie goodness. Seriously, I am so stoked.
Jubili
1515 Fillmore Street, San Francisco, CA 94115
Tuttimelon
2150 Irving Street, San Francisco, CA
Monday, February 04, 2008
Words Only Dead People Should Know
"Don't laugh at me, okay?" I said, "I made up a story to help us memorize the urea cycle."
"Okay," said Paul, sitting down.
"It's sort of a mythological story of origin, okay? In the beginning, there was only CO2 and NH4+, but 2 ATP were invested to create the first man, named Carl (carbamoyl phosphate). Carl mated with a bird goddess, named Ornithine, and together they had a daughter named Citrulline who was actually an orange fruit. Citrulline was all happy and innocent until one day she was bitten by an ASP (aspartate), which turned her bad and sucky (argininosuccinate). Since she changed names to reflect her new identity, like J.Lo, Argininosuccinate started smoking (release fumarate, "fumar" means to smoke in Spanish). She quit smoking, however, and reformed like Lindsay Lohan (haha), changing her name to plain Arginine. Then Arginine drank some magic water (H20) and peed (urea), transforming Arginine into her mother, Ornithine."
There was a short silence. Then Paul said, "So man screws a bird --"
"Bird GODDESS."
"And the bird lays an orange. Then a...what is an ASP?"
"It's a poisonous snake, can't you see the drawing?"
"It sounds more like ASS to me, so a DONKEY bites the orange and turns it evil."
"Fine," I said, "A DONKEY bites the orange. Geez, you don't know what an ASP is?"
"No," Paul said.
"It's the snake that bit Cleopatra," I said.
"That's a COBRA," Paul replied.
"NO, it was an ASP," I insisted.
Later that week, I referred to Wikipedia to resolve the COBRA/ASP issue, and found that ASP is an ARCHAIC term for several poisonous snakes, and that it has fallen out of common usage. In fact, many believe that the "asp" mentioned in ancient and Elizabethan literature as the snake that killed Cleopatra is the COBRA.
I had to apologize to Paul and then reevaluate my vocabulary -- am I using words that only dead people should know? Outdated and antiquated words are charming when you know that they are actually dead, but it's another thing to run around saying a person with TB has "consumption" and believing that you're using modern terminology.
Now I just feel like an idiot in a time capsule. I would blame Harvard for this, because certainly there are many people there who relish learning dead tongues and forgotten customs (some of them in the English Department). In fact, there are a fair number of people there who would probably be better equipped to live in 12th century society, but I never suspected myself to be one of them.
"Okay," said Paul, sitting down.
"It's sort of a mythological story of origin, okay? In the beginning, there was only CO2 and NH4+, but 2 ATP were invested to create the first man, named Carl (carbamoyl phosphate). Carl mated with a bird goddess, named Ornithine, and together they had a daughter named Citrulline who was actually an orange fruit. Citrulline was all happy and innocent until one day she was bitten by an ASP (aspartate), which turned her bad and sucky (argininosuccinate). Since she changed names to reflect her new identity, like J.Lo, Argininosuccinate started smoking (release fumarate, "fumar" means to smoke in Spanish). She quit smoking, however, and reformed like Lindsay Lohan (haha), changing her name to plain Arginine. Then Arginine drank some magic water (H20) and peed (urea), transforming Arginine into her mother, Ornithine."
There was a short silence. Then Paul said, "So man screws a bird --"
"Bird GODDESS."
"And the bird lays an orange. Then a...what is an ASP?"
"It's a poisonous snake, can't you see the drawing?"
"It sounds more like ASS to me, so a DONKEY bites the orange and turns it evil."
"Fine," I said, "A DONKEY bites the orange. Geez, you don't know what an ASP is?"
"No," Paul said.
"It's the snake that bit Cleopatra," I said.
"That's a COBRA," Paul replied.
"NO, it was an ASP," I insisted.
Later that week, I referred to Wikipedia to resolve the COBRA/ASP issue, and found that ASP is an ARCHAIC term for several poisonous snakes, and that it has fallen out of common usage. In fact, many believe that the "asp" mentioned in ancient and Elizabethan literature as the snake that killed Cleopatra is the COBRA.
I had to apologize to Paul and then reevaluate my vocabulary -- am I using words that only dead people should know? Outdated and antiquated words are charming when you know that they are actually dead, but it's another thing to run around saying a person with TB has "consumption" and believing that you're using modern terminology.
Now I just feel like an idiot in a time capsule. I would blame Harvard for this, because certainly there are many people there who relish learning dead tongues and forgotten customs (some of them in the English Department). In fact, there are a fair number of people there who would probably be better equipped to live in 12th century society, but I never suspected myself to be one of them.
Sunday, February 03, 2008
Aphasia
Strange when struggling with writer's block for over a year, and only just recovering, that you find a personal entry that captures something felt almost 2 years ago and now.
April 5, 2006
I haven’t written in this diary for a long time, but I just wanted to say that so much has happened within the past month, maybe even the whole year…I wish I had written more of my thoughts down so that I could read them again years later and be refreshed…reminded of myself when I have already forgotten. It’s too hard writing things down on my blog, because it’s public and I don’t want everyone to see what I really think or feel. So much thoughts clustered at the edges of my lips, I can’t let them out for fear of trying.
April 5, 2006
I haven’t written in this diary for a long time, but I just wanted to say that so much has happened within the past month, maybe even the whole year…I wish I had written more of my thoughts down so that I could read them again years later and be refreshed…reminded of myself when I have already forgotten. It’s too hard writing things down on my blog, because it’s public and I don’t want everyone to see what I really think or feel. So much thoughts clustered at the edges of my lips, I can’t let them out for fear of trying.
Saturday, February 02, 2008
Free Hepatitis B Screening & Vaccination
Hepatitis B: Testing (No Fee) and Vaccination (Low Cost)
Mt Zion UCSF Medical Center
2330 Post Street(near Divisadero St)
San Francisco, CA 94115
(415) 885-3580
1st Saturday of each month (9 AM - 12 noon)
Mar 1, 2008
Apr 5, 2008
May 3, 2008
Jun 7, 2008
Hepatitis B: Testing (No Fee) and Vaccination (Low Cost)
Chinatown Public Health Center
1490 Mason Street (near Broadway St)
San Francisco, CA 94133
(415) 364-7910
2nd Saturday of each month (9 AM - 12 noon)
Feb 9, 2008
Mar 8, 2008
Apr 12, 2008
May 10, 2008
Jun 14, 2008
Mt Zion UCSF Medical Center
2330 Post Street(near Divisadero St)
San Francisco, CA 94115
(415) 885-3580
1st Saturday of each month (9 AM - 12 noon)
Mar 1, 2008
Apr 5, 2008
May 3, 2008
Jun 7, 2008
Hepatitis B: Testing (No Fee) and Vaccination (Low Cost)
Chinatown Public Health Center
1490 Mason Street (near Broadway St)
San Francisco, CA 94133
(415) 364-7910
2nd Saturday of each month (9 AM - 12 noon)
Feb 9, 2008
Mar 8, 2008
Apr 12, 2008
May 10, 2008
Jun 14, 2008
Be Hep B Free
Butterfly needle This morning I volunteered at the new hepatitis B clinic at Mt. Zion, run by the San Francisco Hepatitis B Collaborative (SFHBC).
Some of my favorite classmates poured their hearts and souls this year into establishing outreach clinics to screen and vaccinate the San Francisco population against hepatitis B. Two clinics have been running once at month since last November, and today the clinic had a record of 59 people screened (read: phlebotomized) and about 20 people vaccinated. I am so impressed by the time, effort, organization, cooperation, and dedication exhibited by students from the school of medicine, pharmacy, and nursing. Building this clinic from the ground up was a labor of love and patience, and I could already see the impact of spreading awareness and administering vaccines to improve and prolong people's lives -- so incredibly inspirational. :)
As an educator in the morning, I was surprised by how many strangers come into clinic after hearing about the free screening from a friend or advertising with very little knowledge about hepatitis B. People were confused about the difference between hepatitis A and B, didn't know that there is a hepatitis C for which there is no vaccine, and did not know what damage hepatitis could inflict. For more information, visit the SFHBC SITE at http://www.ucsf.edu/sfhbc/hepb/. Talking to patients and teaching them about hep B was even more gratifying than I thought, because you got to spend some quality time with them and gave them some knowledge that would serve them indefinitely (until the next scientific breakthrough). Educating people about hep B is as important as drawing their blood or administering vaccines, because their knowledge dictates their autonomy.
As a phlebotomist later in the morning (we switch roles halfway), I partnered with a nursing student to draw blood for hep B testing and administered IM injections for the hep B vaccine. I lost count of how many phlebotomies I performed today, but I definitely gave 3 vaccine shots. Sorry to switch gears, but here's the story in vignette form:
A married couple entered the narrow exam room, ready to receive their first hep B vaccinations. S, the nursing student, had already administered the first injection to the husband and now it was the wife's turn to be stuck by...me. Watching S carefully screw the needle onto the syringe and drawing 1 cc of the refrigerated hep B vaccine, squirting a bit out to expel air, helped me prepare -- the last time I learned how to administer vaccines was in the fall of 2006 and we practiced injecting water into oranges. It saddened me because the oranges were inedible afterwards.
A friend of mine working for Teach for America mentioned how small children can sense fear and uncertainty in elementary school teachers, and now I realized that patients can also smell uncertainty. It makes them unhappy and nervous; and I've learned to never make sudden movements or giggle nervously. I smiled at the wife and said, "Have you had any problems with needles or blood before?"
She lifted her sleeve, exposing her petite deltoid muscle. I swabbed her arm with alcohol in a Starry Night pattern and hefted the syringe like a dart. To cause the least amount of pain, we're taught to stick the needle quickly. I held my breath and swung the needle into her muscle as fast as possible, pushed in 1 cc of vaccine, and held a piece of gauze against the point of entry while I withdrew the needle with my right hand at the same initial angle (for some reason, I convince myself that this causes less pain). The patient pressed the gauze against her wound and a band-aid was applied. She didn't seem perturbed at all, while I tried not to act too elated -- it was the first IM injection that I had ever administered to a live person. In medicine, we play it cool...like a cucumber wearing a white coat.
Administering vaccines turned out to be easier than drawing blood! After the first IM injection, it was like throwing darts but much more satisfying. My goal was the cause the least amount of discomfort, because I feel that poking needles as painlessly as possible is a valuable and admirable skill. But drawing blood requires more coordination and skill in selecting and coaxing the right vein to give up some sangre. Asian women are notorious for having no vasculature in the antecubital fossa (behind the elbow). One woman in our exam room seemed to have a promising vein, but it collapsed and S had to pull out. An MD tried to draw blood in the opposite arm, but to no avail. The woman was a bit upset at this point, because we had poked her twice without success, but a third try was the charm.
After the patient left, another Asian lady arrived and it was my turn to draw her blood. In front of a TV camera. For the first time, I tried chatting with the patient to distract her and we made small talk while I set up the supplies and searched for a good vein. I've become convinced that a sucessful phlebotomy depends less upon the skill of the health care provider and more upon the juiciness of the patient's veins -- big, blue, hydrated veins that feel spongy to the fingertip. I harbor a suspicion for veins that look too close to the surface, bright blue sirens that appear to be an easy mark, tempting you to puncture them, only to shipwreck you on a fruitless "stick." I was equally suspicious of a dark blue "Y" shaped vein on her right forearm, was it scarred down? Was it eager for a blood draw? The MD told me to go ahead, and I carefully slid the butterfly needle into the skin -- saw that ever-gratifying "FLASH" of blood in the butterfly needle and slid on the vacuum tube to pull blood into the container. There was a video camera pointed at the patient's arm less than 3 feet away, but the only mishap occurred when the vacuum tube lost suction and blood stopped pooling into the container. I nervously told the MD about the problem before tightening the syringe and seeing blood flow. Then I started breathing again.
Thursday, January 31, 2008
Kessler
From today's Synapse
"The Impact of Dean Kessler’s Dismissal on Students at the UCSF School of Medicine"
More than a month has passed since Dr. David Kessler unexpectedly announced the termination of his appointment as dean of the School of Medicine at UCSF in a puzzling e-mail sent to medical students and faculty members on December 14, 2007.
In the oft-quoted missive, Dr. Kessler alleges that his efforts to rectify “a series of financial irregularities that predated [his] appointment” led “the university” to characterize him as “a whistleblower.” In June 2007, UCSF Chancellor Dr. J. Michael Bishop requested the former FDA commissioner’s resignation. Although Dr. Kessler refused, the Chancellor formally terminated his appointment as dean on Thursday, December 13, 2008, “effective immediately.”
In his correspondence with Synapse, Dr. Bishop declined to comment and referred to his statement released December 17, 2007. The Chancellor declares that “action was taken only after extensive deliberations over many months among the leadership at UCSF, the President and Provost of the University of California, and appropriate Regents.” Dr. Bishop also asserts that “the University categorically denies that the action was taken in retaliation for any allegation lodged against the School of Medicine or the University,” and that “the reasons for dismissal must be held in confidence, in compliance with university policy and state law.” Finally, the Chancellor maintains that “Three separate reviews of the School’s finances were performed over the course of the past three years by three separate agencies. All found the finances to be sound, and none uncovered any evidence of financial irregularities.”
Nevertheless, the abrupt dismissal of a high-profile dean from a well-known medical school has prompted a flurry of local and national media coverage. Moreover, the unorthodox method in which Dr. Kessler announced his startling dismissal has ignited a firestorm of gossip and speculation among medical students and faculty in the vacuum created by the absence of any detailed official account.
A second-year medical student who requested his name be withheld remarked that Dr. Kessler’s e-mail “dropped the bomb and then forwarded news articles filled in a fuzzy picture. The situation is confusing because we don’t know who was wronged. But ultimately, I am not worried that the changes will affect our education or UCSF’s standing.”
A fourth-year medical student who also requested his name to be withheld commented, “It’s disappointing that the individuals involved were not able to place the needs and interests of the UCSF community first in this process and instead chose to air their discontent publicly.”
Several found the timing of Dr. Kessler’s dismissal in December when most students were away or preparing for winter break to be problematic. Although the event may have been precipitated by factors out of the control of either party, Jesse Klafter (MS1) voiced a concern that the incident occurred “right before Christmas to prevent school and media scrutiny of their actions.” Whether the occasion was premeditated or not (most aspects point to the contrary), the inopportune timing of Dr. Kessler’s dismissal has prevented satisfactory public discussion within the campus-wide community, which will be remedied in the next few months according to representatives from the Associated Students of the School of Medicine (ASSM), our student body government.
During a Student Faculty Liason Committee (SFLC) meeting on January 16, 2008, ASSM Secretary Vignesh Arasu (MS2) remarked, “Students didn’t feel prepared to hear the news. The timing was just at the beginning of our vacation, or for us second years, the day before our final exam. We have moved on, but not without lingering questions in the back of our head. We are also concerned with how it has affected our reputation, in terms of recruiting future students and faculty. According to many fourth years who are interviewing for residency, they have been asked about the firing in their interviews and put in a difficult situation to provide a realistic answer.”
On the ASSM discussion board, Arasu articulated another key issue: “There are also reasons against pursuing [Dr. Kessler’s dismissal] further. Is this divisive? Will this prevent us from moving forward as a school? Will anything come out of this? Will we be pulling ourselves into the middle of a controversy that we don’t want? Will this hold us back from accepting interim Dean Hawgood? But I remind you that there have been further facts about the situation that various people have gotten through faculty and that Dean Kessler has shared with the news outlets, but there is nothing that we have been officially told.”
The most troubling aspect of the dismissal has thus proven to be lack of transparency. Fortunately, UCSF has taken measures to correct this official reticence by arranging for the Interim Dean, Dr. Sam Hawgood, to speak at the SFLC meeting on January 16.
“Dean Hawgood went into a lengthy discussion of the events and his interpretation. Overall, and I feel like I can speak for all of us present at the meeting, Hawgood came across as honest and frank, and didn’t try to avoid the issue and was open to questions,” observed Arasu.
Irene Kang (MS2 ASSM representative) added that Dean Hawgood “believes in the integrity of both Dean Kessler and Chancellor Bishop, and doesn’t feel either is wrong in this situation. He has looked at all the same financial documents as Dean Kessler has and believes Dean Kessler’s interpretation of the finances is really a matter of perspective, as there are ‘many ways’ of looking at the numbers. After reviewing many reports, he has come to shares the sentiment of the Chancellor that UCSF is not in debt but in fact in strong financial condition.”
Moreover, Dean Hawgood pointed out at the ASSM meeting that “since the Dean serves “at the pleasure” of the Chancellor… the reasons for his firing may be as simple as a clash of personalities. He does not believe the firing was a result the Dean’s difference of opinion on finances. What may be implied is that the firing was a cumulative effect of many conflicting points of view over the time that they spent working together.”
Most importantly, ASSM representatives noted that “Dean Hawgood is interested and willing to hold a public forum with students for him to introduce himself, describe what has happened as he did at the ASSM meeting, do a Q&A, and discuss the search committee for selecting the future dean.”
"The Impact of Dean Kessler’s Dismissal on Students at the UCSF School of Medicine"
More than a month has passed since Dr. David Kessler unexpectedly announced the termination of his appointment as dean of the School of Medicine at UCSF in a puzzling e-mail sent to medical students and faculty members on December 14, 2007.
In the oft-quoted missive, Dr. Kessler alleges that his efforts to rectify “a series of financial irregularities that predated [his] appointment” led “the university” to characterize him as “a whistleblower.” In June 2007, UCSF Chancellor Dr. J. Michael Bishop requested the former FDA commissioner’s resignation. Although Dr. Kessler refused, the Chancellor formally terminated his appointment as dean on Thursday, December 13, 2008, “effective immediately.”
In his correspondence with Synapse, Dr. Bishop declined to comment and referred to his statement released December 17, 2007. The Chancellor declares that “action was taken only after extensive deliberations over many months among the leadership at UCSF, the President and Provost of the University of California, and appropriate Regents.” Dr. Bishop also asserts that “the University categorically denies that the action was taken in retaliation for any allegation lodged against the School of Medicine or the University,” and that “the reasons for dismissal must be held in confidence, in compliance with university policy and state law.” Finally, the Chancellor maintains that “Three separate reviews of the School’s finances were performed over the course of the past three years by three separate agencies. All found the finances to be sound, and none uncovered any evidence of financial irregularities.”
Nevertheless, the abrupt dismissal of a high-profile dean from a well-known medical school has prompted a flurry of local and national media coverage. Moreover, the unorthodox method in which Dr. Kessler announced his startling dismissal has ignited a firestorm of gossip and speculation among medical students and faculty in the vacuum created by the absence of any detailed official account.
A second-year medical student who requested his name be withheld remarked that Dr. Kessler’s e-mail “dropped the bomb and then forwarded news articles filled in a fuzzy picture. The situation is confusing because we don’t know who was wronged. But ultimately, I am not worried that the changes will affect our education or UCSF’s standing.”
A fourth-year medical student who also requested his name to be withheld commented, “It’s disappointing that the individuals involved were not able to place the needs and interests of the UCSF community first in this process and instead chose to air their discontent publicly.”
Several found the timing of Dr. Kessler’s dismissal in December when most students were away or preparing for winter break to be problematic. Although the event may have been precipitated by factors out of the control of either party, Jesse Klafter (MS1) voiced a concern that the incident occurred “right before Christmas to prevent school and media scrutiny of their actions.” Whether the occasion was premeditated or not (most aspects point to the contrary), the inopportune timing of Dr. Kessler’s dismissal has prevented satisfactory public discussion within the campus-wide community, which will be remedied in the next few months according to representatives from the Associated Students of the School of Medicine (ASSM), our student body government.
During a Student Faculty Liason Committee (SFLC) meeting on January 16, 2008, ASSM Secretary Vignesh Arasu (MS2) remarked, “Students didn’t feel prepared to hear the news. The timing was just at the beginning of our vacation, or for us second years, the day before our final exam. We have moved on, but not without lingering questions in the back of our head. We are also concerned with how it has affected our reputation, in terms of recruiting future students and faculty. According to many fourth years who are interviewing for residency, they have been asked about the firing in their interviews and put in a difficult situation to provide a realistic answer.”
On the ASSM discussion board, Arasu articulated another key issue: “There are also reasons against pursuing [Dr. Kessler’s dismissal] further. Is this divisive? Will this prevent us from moving forward as a school? Will anything come out of this? Will we be pulling ourselves into the middle of a controversy that we don’t want? Will this hold us back from accepting interim Dean Hawgood? But I remind you that there have been further facts about the situation that various people have gotten through faculty and that Dean Kessler has shared with the news outlets, but there is nothing that we have been officially told.”
The most troubling aspect of the dismissal has thus proven to be lack of transparency. Fortunately, UCSF has taken measures to correct this official reticence by arranging for the Interim Dean, Dr. Sam Hawgood, to speak at the SFLC meeting on January 16.
“Dean Hawgood went into a lengthy discussion of the events and his interpretation. Overall, and I feel like I can speak for all of us present at the meeting, Hawgood came across as honest and frank, and didn’t try to avoid the issue and was open to questions,” observed Arasu.
Irene Kang (MS2 ASSM representative) added that Dean Hawgood “believes in the integrity of both Dean Kessler and Chancellor Bishop, and doesn’t feel either is wrong in this situation. He has looked at all the same financial documents as Dean Kessler has and believes Dean Kessler’s interpretation of the finances is really a matter of perspective, as there are ‘many ways’ of looking at the numbers. After reviewing many reports, he has come to shares the sentiment of the Chancellor that UCSF is not in debt but in fact in strong financial condition.”
Moreover, Dean Hawgood pointed out at the ASSM meeting that “since the Dean serves “at the pleasure” of the Chancellor… the reasons for his firing may be as simple as a clash of personalities. He does not believe the firing was a result the Dean’s difference of opinion on finances. What may be implied is that the firing was a cumulative effect of many conflicting points of view over the time that they spent working together.”
Most importantly, ASSM representatives noted that “Dean Hawgood is interested and willing to hold a public forum with students for him to introduce himself, describe what has happened as he did at the ASSM meeting, do a Q&A, and discuss the search committee for selecting the future dean.”
Side Projects
Kara's Cupcakes in Ghiradelli Square, SFAside from Synapse, studying, and teaching MSP, I realized last Sunday that there are a variety of "side projects" of varying intensity that occupy my time and interest. Some of them are quirky, some of them are serious, some of them have deadlines, and all of them are strangely absorbing.
1) The Loose Change Project: After finding 3 lbs. of loose change in my backpack (leaky wallet syndrome), I placed all my loose change in a purple suede baggie and currently try to use up all my coins by paying exact change at Moffiteria, MUNI, whenever I remember. It's OCD, I know. GOAL: Use up all my change without caving into the monopoly known as CoinStar.
2) The Napa Project: I heart wine. GOAL: To visit 70% of Napa's wineries with Paul by 2010 (the year we "graduate" from UCSF). 70% is the cut-off to pass an exam in medical school, it makes sense that we should exact the same standards on life outside medical school. We wouldn't be premed without a spreadsheet, too, now would we?
3) Biostatistics Project: Because it's fun to take imaginary grad classes during I3! GOAL: To pass Stan Glantz's biostatistics class in the fall of 2007. Completed!
4) French Laundry Project: Because the waiting list is 6 months. GOAL: To eat here. Some day.
5) Surgical Skills Project?: To learn surgical skills, because I don't want to be whipped in the OR by an attending. GOAL: To take an elective for credit (as a SECOND year? Who DOES that??).
6) Candle Project: Because burning free candles is like reading a really satisfying novel. GOAL: To burn all my candles into little stubs.
7) Jeopardy! Project: Because I'm addicted to fast-paced quiz shows. GOAL: To be on Jeopardy someday? Not much progress on this project...
8) Boba Project: Because they put nicotine in those tapioca balls. GOAL: To drink boba as much as humanly possible...no deadline.
9) Books for Pleasure Project: Because reading makes you a better person. GOAL: To finish "Master and Margarita," to read "Middlemarch," and a few Elizabethan dramas.
10) Secret Projects!
Boy, this was the most un-serious post in recent memory.
Tuesday, January 29, 2008
It's Knot Supposed to be Hard
Yesterday, we had our first Surgical Skills elective class in a squeaky clean lab at Mt. Zion. We had plastic boards with pegs on it (like in kindergarten) and big shoe strings. For over an hour, we learned how to tie surgical knots -- the basic two-handed surgeon's knot and the one-handed knot. It was a lot harder than we expected! In the end, I was really satisfied with the time spent in the lab and felt like it was extremely useful knowledge. :)
Monday, January 21, 2008
Defective Fear Receptor
Tomorrow is the Life Cycle midterm and I have spent all day at home...procrastinating and still wearing my pajamas.
Despite the fact that I have only skimmed up to page 284 of a 346-page syllabus (retention rate about 40%) and went to see "Juno" last night with medical school friends, I am still not focused enough to study.
In fact, I'm more disturbed by the lack of fear response. This only confirms my suspicion that I may have been born with a latent congenital abnormality -- a defective fear receptor.
Despite the fact that I have only skimmed up to page 284 of a 346-page syllabus (retention rate about 40%) and went to see "Juno" last night with medical school friends, I am still not focused enough to study.
In fact, I'm more disturbed by the lack of fear response. This only confirms my suspicion that I may have been born with a latent congenital abnormality -- a defective fear receptor.
You Saw a What?
Bird"At Mission Bay today I saw a yellow-rumped warbler," said Paul.
"You saw a what," I said.
"A Yellow-Rumped Warbler."
"A what?" I said.
"A pretty warbler with a yellow ass!" he said.
"Ohh...you saw a BIRD," I said.
Paul paused for a moment before saying, "...Yes."
Thursday, January 17, 2008
Ode to PCR
Forwarded to the class by a schoolmate...for all you nerds and nerd-lovers...a song about PCR!
http://www.cnpg.com/video/redirect.aspx?redirectid=65
http://www.cnpg.com/video/redirect.aspx?redirectid=65
Wednesday, January 16, 2008
I Try Really Hard, Actually
DSL remarked this afternoon, "There's a line in the movie 'Juno' that I really liked...
Juno: I think I'm in love with you.
Paulie Bleeker: You mean as friends?
Juno: No, I mean, for real. 'Cause you're, like, the coolest person I've ever met, and you don't even have to try, you know...
Paulie Bleeker: I try really hard, actually."
We talked about how lots of things...like getting your errands done at Walgreen's, buying bread in Cole Valley, and basically keeping your life from degenerating into a state of entropy requires extraordinary effort. And when life actually functions, it looks effortless. Isn't that ironic? Like a sculpture that looks effortlessly crafted or an Olympic ski jump that looks so carefree...things that take enormous amounts of effort, energy, training, thought to be distilled into 1 object or moment that looks as though it took no effort at all.
What paradox!
Juno: I think I'm in love with you.
Paulie Bleeker: You mean as friends?
Juno: No, I mean, for real. 'Cause you're, like, the coolest person I've ever met, and you don't even have to try, you know...
Paulie Bleeker: I try really hard, actually."
We talked about how lots of things...like getting your errands done at Walgreen's, buying bread in Cole Valley, and basically keeping your life from degenerating into a state of entropy requires extraordinary effort. And when life actually functions, it looks effortless. Isn't that ironic? Like a sculpture that looks effortlessly crafted or an Olympic ski jump that looks so carefree...things that take enormous amounts of effort, energy, training, thought to be distilled into 1 object or moment that looks as though it took no effort at all.
What paradox!
Tuesday, January 15, 2008
"Dying Words"
Excellent piece from the New Yorker. The author really captures the pain and slight melancholy of oncology...and it reflects on our excellent clinical training at UCSF which has focused on death and dying for the past two weeks.
A speaker pointed out that we are currently learning about reproduction and palliative care simultaneously...eros and thanatos as we learned in English...sex and death always seem to go hand-in-hand.
Full Text :COPYRIGHT 2002 All rights reserved. Reproduced by permission of The Condé Nast Publications Inc.
Not long ago, I had an appointment with a patient who was likely to die within a year and a half. Maxine Barlow was a twenty-eight-year-old teacher in Boston. The only child of a middle-class family, she had recently become engaged to a financial analyst, Peter Wayland (all names have been changed). One morning in the shower, Maxine found a small lump in her breast, a little larger than a pea. A biopsy showed that it was breast cancer. Further tests revealed that the cancer had spread to Maxine's spine and liver, which meant that surgery could not fully remove it, and Maxine's surgeon referred her to me for chemotherapy.
Maxine and I met on a brisk autumn afternoon. Her appointment was my last of the day, since our conversation was likely to extend beyond the hour usually allotted to new patients. I had to explain the gravity of her condition and the possible choices she could make.
After I had examined Maxine, we were joined in my office by her parents and by Peter. They sat in a semicircle facing me, with Maxine between them. I moved my chair out from behind my desk.
"Let's review what was found at surgery," I began. Maxine reached for Peter's hand. Although I addressed Maxine, I also briefly met the gaze of her parents and of Peter, in order to engage everyone. "The cancer in the breast measured one and a half centimetres, about half an inch, and under the microscope the cancer cells were actively dividing," I said. "They should be treated aggressively. The tests we did on the tumor showed that it is not sensitive to hormones"--which ruled out Tamoxifen, a common hormone-blocker. "The scan showed that several deposits of tumor had spread from the breast to the bones in the neck. There also are four deposits in the liver. We can treat them with chemotherapy, which destroys the cancer cells wherever they might be lurking. The good news is that you stand a very strong chance of going into remission."
"So that means that she'll be O.K.?" Maxine's mother asked.
My stomach tightened in a familiar way. This part never got any easier.
"Remission does not mean cure," I said. "Remission means that all the cancer we can measure disappears. Therapy is palliative."
"What do you mean, 'palliative'?" Peter asked in a panicked voice.
"She has to be cured," Maxine's father said.
This distinction was important, and I needed to make sure, gently but unequivocally, that they understood. "There is a very good chance that we will see the metastatic deposits in your bones and liver shrink significantly, or completely melt away. But the most intensive chemotherapy or radiation available--even bone-marrow transplant--is not enough to destroy every cancer cell in your body. That is why, currently, we cannot say the cancer can be cured."
Maxine sat without speaking. Her eyes filled with tears, and I gave her some tissues.
"What is the point of treatment, then?" I asked. "Palliation. That means that even if the cancer cannot be cured it can be controlled. The best-case scenario is that the cancer becomes like a parasite," I said, purposefully invoking a stark image. "We knock it down with the therapy, and hope that it stays down for many, many months or years. You can live an active life--work, jog, travel, whatever. The bones and liver can heal. And when the cancer returns we work to knock it down again. All the while, we hold on to the hope that an experimental treatment will be found that is able to eradicate the cancer--to truly cure you."
Like Maxine, Mrs. Barlow was fighting back tears. Her husband stared at me. I paused before broaching a second critical issue.
"We talked about the best-case scenario. But we also have to acknowledge that there is a worst-case scenario."
I had found that this part of the discussion was best completed rapidly, as if removing an adhesive bandage.
"The worst-case scenario is that ultimately the cancer becomes resistant to all the treatments we have, and even experimental therapies are no use. Most people say that if they reach a point in the illness when their brain is impaired, and there is no likelihood of improving their quality of life, then nothing should be done to keep them artificially alive, through machines like respirators. It's essential, Maxine, that I know what you want done if we reach that point."
"I--I don't think I would want that," she said, haltingly.
"You mean that you would want only comfort measures to alleviate pain, and nothing done to prolong your life, like a respirator or cardiac resuscitation?"
"Yes, I think so," Maxine whispered.
I nodded. This was her "end-of-life directive." I would put it in writing in her medical chart.
"We have a plan of therapy and an understanding. Now let's look on the positive side," I said, trying to spark some of the determination she would need in order to endure the months of chemotherapy ahead. "You are young, your organ function is excellent--despite the deposits of tumor, your liver is still working well, and your blood counts are fine--so there is every reason to think that you will tolerate the drugs and we will make real progress."
I smiled confidently. Maxine struggled to do the same.
"But what are the exact odds for a remission?" Peter Wayland asked. "I mean, how many patients like Maxie stay in remission and for how long, on average?"
Maxine looked at him sharply. "Dr. Groopman said that there is every reason to think I'll go into remission," she said. "What more do we need to know now?"
She turned to me, her face full of uncertainty.
This was a crucial moment in our interview. There were several ways that I could answer Peter's question. I could give the bald statistics--that more than fifty per cent of people with cancer like Maxine's die within two years--or I could put it more gently, and say that she had a chance, if a low one, of surviving for more than two years. I could even say, somewhat vaguely, that she was young and strong and had as good a chance as anyone of surviving, on the principle that she would benefit more from encouragement than from statistics. As I looked at Maxine, I sensed that she preferred neither the extreme of ignorance nor the extreme of excruciating detail but some middle ground.
"Statistics don't say anything about any particular individual, only about groups," I said. "There can be wide variability in the behavior of any cancer in each person, because each of us is different--different genetically, living in a different environment--and we metabolize the treatments differently.
"I want my patients to be informed," I said, looking now at Peter. "When Maxine said she understood there is a very good chance of remission, that is accurate. It could last months or it could last years. Putting precise numbers on it at this point doesn't really tell us anything more about Maxine. In the meantime, we need to plan for the best while acknowledging the worst."
Oncologists give bad news to patients some thirty-five times per month on average, telling a patient that he has cancer, that his tumor has come back, that his treatment has failed, that no further treatment would be helpful. And yet there is no agreement among specialists about how to deliver such news. More than forty per cent of oncologists withhold a prognosis from a patient if he or she does not ask for it or if the family requests that the patient not be told. A similar number speak in euphemisms, skirting the truth. Today, in most of Europe doctors often do not tell patients that they are dying.
Until recently, many doctors rarely informed their patients that there was nothing to be done for them; conventional wisdom had it that patients ought to be spared the anguish of knowing that they were going to die. The renowned physician Sir William Osler, who, at the turn of the last century, wrote the seminal textbook "The Principles and Practice of Medicine," emphasized the importance of keeping the patient optimistic. "It wasn't the style to be specific," Dr. David Golde, a former physician-in-chief at Memorial Sloan-Kettering Cancer Center, said of his medical training, which began in 1962. "The patient's questions and the doctor's answers--both avoided detail. And doctors never volunteered to give more information. Of course, there were no formalized end-of-life directives. The doctor's duty to ease the path was unspoken." When I asked him what he meant by not being specific, he said, "The doctor would say, 'Yes, you have a serious disease.' "
In 1969, a book called "On Death and Dying," by Elisabeth Kubler-Ross, which later became a best-seller, made death an acceptable subject for discussion between patients and doctors for the first time. In the nineteen-eighties, cultural and political changes in America--some precipitated by AIDS--introduced the notion that a patient had a right to know everything his doctor knew. In 1993, Sherwin Nuland's book "How We Die," which won the National Book Award, described in detail the psychology and physiology of death.
As medical practice grows more sophisticated more people are living longer with the knowledge that they may be dying. Decisions made in the late stages of illness are increasingly an aspect of treatment. Dying requires emotional and physical stamina from the individual and his family. And the difficulty of negotiating all this has an effect on doctors as well as patients. A recent article reported that more than half of the oncologists interviewed say that the frequent witnessing of death leads to an overwhelming sense of fatigue and futility; the profession has one of the highest burnout rates in medicine.
Despite this, during my nine years of medical school and professional training in the nineteen-seventies, I was never instructed in how to speak about dying to a gravely ill patient and the patient's family. It was presumed that, as medical students, we learned how to deliver bad news through careful observation of our mentors, just as we learned how to lance a deep abscess by watching doctors and then trying it ourselves. But most physicians preferred to speak to their patients in private. And the subject was never raised in our classrooms.
As an oncology fellow, I began my career believing that it was essential to provide details to my patients. Sharing statistics seemed like the obvious thing to do: surely a patient should have access to everything I knew. Early on, I had a case somewhat similar to Maxine's. Claire Allen was a small, straw-haired librarian in her forties with breast cancer; she was married, with two young children. Like Maxine, she had multiple metastases to bone and liver. We met in my clinic office, and she looked at me expectantly.
"Claire, with this disease, a remission would ordinarily last three to six months," I told her bluntly. "A person could expect to survive between one to two years."
She appeared to take the news stalwartly, but I later learned from her husband that she had left the appointment deeply shaken. She told her children that she had only one Christmas left. Her face was full of despair whenever I saw her. And yet Claire lived for nearly four years. She was able to travel, work part time, and take care of her children, but was unable to stop thinking that she could die at any moment.
Chastened, I tried a different approach. Henry Gold, a short-order cook in his sixties, had acute leukemia that had resisted all treatment. At one point, he asked me what else could be done. I reassured him that there were drugs that had not yet been tried, even though I knew they were unlikely to help. When Henry started to bleed around his lungs, I had the interns drain the hemorrhage with chest tubes; I insisted that he be intubated, supported on a respirator in the I.C.U., and given numerous blood transfusions. His heart developed a dangerous arrhythmia, so I gave orders for cardiac medications and electroshock. I never asked Henry what he wanted. He stayed alive for more than a week on the respirator, a catheter in his heart, tubes in his throat, unable to speak to family and friends who had come to his bedside.
On a chilly morning two days after our first meeting, Maxine returned to the clinic for her first round of chemotherapy. She had insisted on coming alone; Peter would pick her up afterward. The chemotherapy suite is a large, open space that holds twenty or so patients receiving intravenous drugs, some behind curtains, others talking or watching television. Maxine looked at the patients she passed. Most were wearing hats or kerchiefs to cover their bald heads. Several reclined in their chairs, thin and pale, too weak to sit up. It was clear that some of them would soon die.
A half hour after Maxine's chemotherapy treatment, Peter still had not arrived. Maxine's cell phone rang. "He's tied up," she explained to me, and we arranged for a car service to take her home. When I called Maxine later that evening to see how she was doing, Peter answered the phone and told me that she was sleeping.
"She's going to die, isn't she?" he said. He explained that he had been searching the Internet, and had read that in cases like Maxine's patients survived on average eighteen months, and that a remission lasted three to six months at best.
"Peter, as I said when we met, statistics don't tell you what is going to happen to any one person, just groups."
I got off the phone as quickly as I could. There could be no "back channel" discussions with friends or family; if Maxine had wanted to, she could have logged on to the Internet.
Over the next seven months, the metastases in Maxine's bones and in her liver decreased significantly. Although she was frequently tired and lost her hair, she was able to work part time, and even took a weekend trip to Manhattan with her parents and went to Newport for a friend's wedding. Then, on a routine visit at the end of May, after her eighth month of therapy, I noticed that one of her eyes wandered, and she seemed to be tilting her head to the right.
"Are you having any trouble seeing?"
She said that sometimes it was difficult to read.
"Any double vision?"
Yes, she said, on a few occasions that week, when she was walking down stairs.
Movement of the eyes is controlled by a set of cranial nerves at the base of the skull. An initial MRI scan of the brain did not turn up anything abnormal, but scans do not always detect small deposits on the cranial nerves. I explained that a spinal tap was the best way to determine if the cancer had spread to the brain; it would allow us to search for tumor cells in the spinal fluid.
Maxine lay on her side as a medical resident performed the procedure. I tried to distract her. We talked about the Red Sox, who had started the season strong, and whether, as usual, they would end up losing games in the homestretch. After sterilizing and anesthetizing the area between the fourth and fifth lumbar vertebrae, the resident passed a fine trocar into the spinal canal. Maxine twitched. Drops of fluid fell from the trocar into a test tube that he held under it. Normal spinal fluid is clear; Maxine's was cloudy.
"It's over," I said. "Stay down for an hour, so you don't get a headache."
She asked what it meant if the cancer had gone to her cranial nerves.
I was almost certain, based on the cloudiness of the spinal fluid, that this was the case. How much did Maxine want to know?
"It is a major setback," I said.
"I'm not sure I want to ask how long a remission lasts if the cancer is in my brain," she said.
"Are you sure you want to talk about this now?"
Maxine closed her eyes and nodded.
"People usually live several weeks to a few months without any treatment," I said. "But that represents the average. There are people who live longer. Treatment with radiation and chemotherapy instilled into the spinal fluid may or may not extend life, but it can reduce some of the most annoying complications, like the double vision."
Maxine was silent. "Is it even worth being treated?" she finally asked.
"You are the only one who can answer that question," I said. "If we don't treat it, it will quickly spread to other cranial nerves and parts of the brain and spinal cord. The quality of your life would be markedly impaired. I want to help sustain as much quality of life for as long as possible."
Maxine opened her eyes.
"I don't want to die," she said, beginning to sob. "I didn't think it would happen so fast, so soon. I'm not ready to die."
"I don't want to lose you," I said. There was nothing more I could say now that would help.
"Let's go step by step, and talk after the results from the spinal tap."
Later that day, I went to the pathology laboratory. Under the microscope, numerous large cells, with distorted nuclei, filled what should have been an empty field. "Carcinoma," the pathologist said.
Over the next few weeks, we began radiation treatment and a new round of chemotherapy, infused into her spinal fluid. At first, Maxine's double vision improved. But after three weeks or so she found that she couldn't move her left eye, and we put a patch over it. Shortly thereafter, the left side of her face began to droop. A second MRI showed that the cancer had spread to the membranes lining the cerebral cortex and spinal cord. It was evening when I came into Maxine's hospital room. She was watching television.
She turned to me as I switched off the TV.
"Peter left me."
I nodded, saying that I had noticed that he was not around the past few days.
"He's been seeing someone else the past three months."
I remained silent.
"I always felt, deep inside, that he was weak." Maxine paused. "No, not just weak. He's a schmuck. A real schmuck."
"Do you know what that word literally means in Yiddish?" I asked.
Maxine laughed.
I took her hand. She tried to press back, but had little force. The nerves from the cervical spinal cord were being compressed by the deposits of cancer.
"I'm not sure how much strength I have left," Maxine said. She was in a fragile condition. It was time to assess clinical issues.
"Remember once I asked you what your wishes were if we reached a point when further therapy would not improve the quality of your life?"
Maxine nodded. "So you think it's just a few days?" she asked. Her voice was hollow.
"Probably more than just a few days," I said. "Probably weeks. Or maybe longer--I've been wrong before."
"And really nothing can be done?"
Like all patients, Maxine was finding it almost impossible to give up hope.
"Nothing that I know of," I said. "And to continue to give you chemotherapy would not improve the time we have left. But anything I can do to make the time that we have left good for you, I'll do."
Maxine turned away. "How do I actually die from the cancer?"
"You lose consciousness, go into a coma, and either you stop breathing or your heart stops. But you're not aware of any of it."
She was silent as I sat holding her hand.
The first time I witnessed death was in my second year of medical school. My father had had a massive, unexpected heart attack, and I went to meet my mother at the hospital in Queens. The sheets were drenched with sweat. His eyes were filmy and repeatedly rolled upward. Coarse, grunting noises punctuated his breathing, and his chest heaved. His limbs jerked wildly. This went on for nearly half an hour, as a large clock on the wall ticked off the minutes. Then, after a last convulsion, a pink foam poured from his mouth, his head snapped back, the little color remaining in his skin drained away, and he was still.
I held my mother, numb with disbelief. The doctor on call, whom we did not know and who had stood by as we watched, closed the curtain around the bed. He looked at me holding my mother, and said weakly, "It's tough, kid."
Although I later learned that the flailing movements of my father's limbs were the result of neurological reflexes, and that he had not been conscious, I could not stop wondering if he had suffered. The ugliness of these final minutes often invades otherwise comforting memories of times we spent together. When I became a physician, I vowed that I would do everything I could to temper such gruesome experiences for the patient and for the family.
During the Middle Ages and the Renaissance, death was supposed to be met with words of welcome. This was the core of ars moriendi--"the art of dying." The "art" prepared and purified the person by linking his experience to Jesus' death on the Cross. Treatises like William Caxton's, printed in 1491, instructed laymen to think about the end of life, even when they were healthy, and dictated what words they should expect to hear and say when death was near:
"This time of your departing shall be better to you than the time of your birth, for now all sickness, sorrow, and trouble shall depart from you forever. Therefore be not aggrieved with your sickness and take it not with grutching but take it rather all by gladness."
Today, the physician frequently finds himself assuming a role that was once the exclusive province of religious authorities. Yet the palliative care he offers is primarily meant to ease physical suffering; he is not trained to alleviate emotional pain. In medical terms, a "good death" is a death with the least physical suffering possible. As ars moriendi suggests, though, there is a historical notion of a "good death" that is more complicated; it is as much about a cultivated attitude toward leaving life as it is about the physical act. Is there more, then, that physicians should do to make dying in a hospital after illness less emotionally taxing?
Last January, one of the first academic studies of how effectively oncologists communicate critical information to their patients was published. A hundred and eighteen patients cared for by nine oncologists participated in the research. The doctor-patient interactions were recorded on audiotape. The study tried to determine two things: whether the information disclosed to the patients was sufficient for them to make an informed decision about further treatment, and whether the doctor encouraged the patient's participation in choosing among treatments.
Although the oncologists knew that they were being taped, in more than a quarter of the consultations the patients were not told that their disease was incurable; a similar percentage were not informed of the side effects associated with the proposed anti-cancer therapy. Only five patients of the hundred and eighteen--some four per cent--received what the researchers considered adequate information. In nearly ninety per cent of the taped discussions, the oncologists failed to ask the patients if they understood the information being presented to them. These results are in keeping with prior research indicating that more than a third of patients with incurable metastatic cancer believe that the treatment offered by their doctors will actually cure them.
Suffering is not the only cost. Many in the medical profession have speculated that doctors' uncertainty in guiding patients through the end of life is one of the primary causes of rising health-care costs. More money is spent on care during the last weeks of life than on the months or years of care that precede it. The kinds of interventions that are routine in an intensive-care unit--pumps to sustain circulation, respirators to ventilate the lungs--cost hundreds of thousands of dollars. Some physicians don't want to acknowledge that a patient is going to die, and regularly order tests and procedures at a point when no reasonable gain can come of them. Studies show that a doctor does not shorten the life of the patient when he chooses to provide palliative rather than intensive care.
...[cut some parts]
After I talked with Maxine, I arranged for her to be transferred to a special hospice unit, and soon she began to drift in and out of consciousness. The cancer pressing on the cranial nerves connected to the back of her throat and her tongue had made it difficult for her to swallow. The nurses had to suction her saliva to prevent her from choking. Shortly before noon a week later, I was paged and told that Maxine's death appeared imminent.
Maxine's parents were sitting by her bed when I came in. They stood up, and Mrs. Barlow hugged me, crying. Mr. Barlow's face was frozen with grief.
Maxine was no longer conscious. Every few seconds, her chest heaved, and she gasped. She was entering what is called the agonal phase--taken from the Greek agon, which means struggle--a period that precedes death and can last from a few minutes to hours.
I warned Maxine's parents that this was usually harrowing, and that sometimes family members preferred not to witness it.
"I want to be with my baby," Maxine's mother said.
Maxine's hands began to twitch and her breathing moved into a syncopated pattern called Cheyne-Stokes, a short set of staccato breaths bracketing a long pause.
Mrs. Barlow raised her head.
"Maxie, we love you, and God loves you."
Mr. Barlow sat straight, his hands clasped in his lap.
Sometimes as a patient dies there is a convulsive burst of muscular activity, like a grand-mal seizure. I braced myself for it when Maxine's fingers began to twitch, as if she were grasping for an invisible object. These muscle contractions continued for some forty minutes. Then a harsh rattling sound came from her chest. I glanced at the nurse, who was next to the morphine infusion. There was a single explosive jerk of Maxine's body, a sharp arching of her chest, followed by a series of fluttering movements in the muscles of her neck.
The Barlows stood up. Maxine's skin was already changing to an ashen hue. I placed my stethoscope over her heart. "I am sorry," the nurse said. I reached over and took Mr. Barlow's hand, and then turned and embraced Mrs. Barlow as she cried.
I left the Barlows and went to the nurses' station to fill out Maxine's death certificate. I designated the primary cause as respiratory failure due to metastatic breast cancer to the brain and handed the chart with the death certificate to the floor clerk. The time of death was 12:57 P.M.
Source Citation:Groopman, Jerome. "DYING WORDS." The New Yorker 78.32 (Oct 28, 2002):
A speaker pointed out that we are currently learning about reproduction and palliative care simultaneously...eros and thanatos as we learned in English...sex and death always seem to go hand-in-hand.
Full Text :COPYRIGHT 2002 All rights reserved. Reproduced by permission of The Condé Nast Publications Inc.
Not long ago, I had an appointment with a patient who was likely to die within a year and a half. Maxine Barlow was a twenty-eight-year-old teacher in Boston. The only child of a middle-class family, she had recently become engaged to a financial analyst, Peter Wayland (all names have been changed). One morning in the shower, Maxine found a small lump in her breast, a little larger than a pea. A biopsy showed that it was breast cancer. Further tests revealed that the cancer had spread to Maxine's spine and liver, which meant that surgery could not fully remove it, and Maxine's surgeon referred her to me for chemotherapy.
Maxine and I met on a brisk autumn afternoon. Her appointment was my last of the day, since our conversation was likely to extend beyond the hour usually allotted to new patients. I had to explain the gravity of her condition and the possible choices she could make.
After I had examined Maxine, we were joined in my office by her parents and by Peter. They sat in a semicircle facing me, with Maxine between them. I moved my chair out from behind my desk.
"Let's review what was found at surgery," I began. Maxine reached for Peter's hand. Although I addressed Maxine, I also briefly met the gaze of her parents and of Peter, in order to engage everyone. "The cancer in the breast measured one and a half centimetres, about half an inch, and under the microscope the cancer cells were actively dividing," I said. "They should be treated aggressively. The tests we did on the tumor showed that it is not sensitive to hormones"--which ruled out Tamoxifen, a common hormone-blocker. "The scan showed that several deposits of tumor had spread from the breast to the bones in the neck. There also are four deposits in the liver. We can treat them with chemotherapy, which destroys the cancer cells wherever they might be lurking. The good news is that you stand a very strong chance of going into remission."
"So that means that she'll be O.K.?" Maxine's mother asked.
My stomach tightened in a familiar way. This part never got any easier.
"Remission does not mean cure," I said. "Remission means that all the cancer we can measure disappears. Therapy is palliative."
"What do you mean, 'palliative'?" Peter asked in a panicked voice.
"She has to be cured," Maxine's father said.
This distinction was important, and I needed to make sure, gently but unequivocally, that they understood. "There is a very good chance that we will see the metastatic deposits in your bones and liver shrink significantly, or completely melt away. But the most intensive chemotherapy or radiation available--even bone-marrow transplant--is not enough to destroy every cancer cell in your body. That is why, currently, we cannot say the cancer can be cured."
Maxine sat without speaking. Her eyes filled with tears, and I gave her some tissues.
"What is the point of treatment, then?" I asked. "Palliation. That means that even if the cancer cannot be cured it can be controlled. The best-case scenario is that the cancer becomes like a parasite," I said, purposefully invoking a stark image. "We knock it down with the therapy, and hope that it stays down for many, many months or years. You can live an active life--work, jog, travel, whatever. The bones and liver can heal. And when the cancer returns we work to knock it down again. All the while, we hold on to the hope that an experimental treatment will be found that is able to eradicate the cancer--to truly cure you."
Like Maxine, Mrs. Barlow was fighting back tears. Her husband stared at me. I paused before broaching a second critical issue.
"We talked about the best-case scenario. But we also have to acknowledge that there is a worst-case scenario."
I had found that this part of the discussion was best completed rapidly, as if removing an adhesive bandage.
"The worst-case scenario is that ultimately the cancer becomes resistant to all the treatments we have, and even experimental therapies are no use. Most people say that if they reach a point in the illness when their brain is impaired, and there is no likelihood of improving their quality of life, then nothing should be done to keep them artificially alive, through machines like respirators. It's essential, Maxine, that I know what you want done if we reach that point."
"I--I don't think I would want that," she said, haltingly.
"You mean that you would want only comfort measures to alleviate pain, and nothing done to prolong your life, like a respirator or cardiac resuscitation?"
"Yes, I think so," Maxine whispered.
I nodded. This was her "end-of-life directive." I would put it in writing in her medical chart.
"We have a plan of therapy and an understanding. Now let's look on the positive side," I said, trying to spark some of the determination she would need in order to endure the months of chemotherapy ahead. "You are young, your organ function is excellent--despite the deposits of tumor, your liver is still working well, and your blood counts are fine--so there is every reason to think that you will tolerate the drugs and we will make real progress."
I smiled confidently. Maxine struggled to do the same.
"But what are the exact odds for a remission?" Peter Wayland asked. "I mean, how many patients like Maxie stay in remission and for how long, on average?"
Maxine looked at him sharply. "Dr. Groopman said that there is every reason to think I'll go into remission," she said. "What more do we need to know now?"
She turned to me, her face full of uncertainty.
This was a crucial moment in our interview. There were several ways that I could answer Peter's question. I could give the bald statistics--that more than fifty per cent of people with cancer like Maxine's die within two years--or I could put it more gently, and say that she had a chance, if a low one, of surviving for more than two years. I could even say, somewhat vaguely, that she was young and strong and had as good a chance as anyone of surviving, on the principle that she would benefit more from encouragement than from statistics. As I looked at Maxine, I sensed that she preferred neither the extreme of ignorance nor the extreme of excruciating detail but some middle ground.
"Statistics don't say anything about any particular individual, only about groups," I said. "There can be wide variability in the behavior of any cancer in each person, because each of us is different--different genetically, living in a different environment--and we metabolize the treatments differently.
"I want my patients to be informed," I said, looking now at Peter. "When Maxine said she understood there is a very good chance of remission, that is accurate. It could last months or it could last years. Putting precise numbers on it at this point doesn't really tell us anything more about Maxine. In the meantime, we need to plan for the best while acknowledging the worst."
Oncologists give bad news to patients some thirty-five times per month on average, telling a patient that he has cancer, that his tumor has come back, that his treatment has failed, that no further treatment would be helpful. And yet there is no agreement among specialists about how to deliver such news. More than forty per cent of oncologists withhold a prognosis from a patient if he or she does not ask for it or if the family requests that the patient not be told. A similar number speak in euphemisms, skirting the truth. Today, in most of Europe doctors often do not tell patients that they are dying.
Until recently, many doctors rarely informed their patients that there was nothing to be done for them; conventional wisdom had it that patients ought to be spared the anguish of knowing that they were going to die. The renowned physician Sir William Osler, who, at the turn of the last century, wrote the seminal textbook "The Principles and Practice of Medicine," emphasized the importance of keeping the patient optimistic. "It wasn't the style to be specific," Dr. David Golde, a former physician-in-chief at Memorial Sloan-Kettering Cancer Center, said of his medical training, which began in 1962. "The patient's questions and the doctor's answers--both avoided detail. And doctors never volunteered to give more information. Of course, there were no formalized end-of-life directives. The doctor's duty to ease the path was unspoken." When I asked him what he meant by not being specific, he said, "The doctor would say, 'Yes, you have a serious disease.' "
In 1969, a book called "On Death and Dying," by Elisabeth Kubler-Ross, which later became a best-seller, made death an acceptable subject for discussion between patients and doctors for the first time. In the nineteen-eighties, cultural and political changes in America--some precipitated by AIDS--introduced the notion that a patient had a right to know everything his doctor knew. In 1993, Sherwin Nuland's book "How We Die," which won the National Book Award, described in detail the psychology and physiology of death.
As medical practice grows more sophisticated more people are living longer with the knowledge that they may be dying. Decisions made in the late stages of illness are increasingly an aspect of treatment. Dying requires emotional and physical stamina from the individual and his family. And the difficulty of negotiating all this has an effect on doctors as well as patients. A recent article reported that more than half of the oncologists interviewed say that the frequent witnessing of death leads to an overwhelming sense of fatigue and futility; the profession has one of the highest burnout rates in medicine.
Despite this, during my nine years of medical school and professional training in the nineteen-seventies, I was never instructed in how to speak about dying to a gravely ill patient and the patient's family. It was presumed that, as medical students, we learned how to deliver bad news through careful observation of our mentors, just as we learned how to lance a deep abscess by watching doctors and then trying it ourselves. But most physicians preferred to speak to their patients in private. And the subject was never raised in our classrooms.
As an oncology fellow, I began my career believing that it was essential to provide details to my patients. Sharing statistics seemed like the obvious thing to do: surely a patient should have access to everything I knew. Early on, I had a case somewhat similar to Maxine's. Claire Allen was a small, straw-haired librarian in her forties with breast cancer; she was married, with two young children. Like Maxine, she had multiple metastases to bone and liver. We met in my clinic office, and she looked at me expectantly.
"Claire, with this disease, a remission would ordinarily last three to six months," I told her bluntly. "A person could expect to survive between one to two years."
She appeared to take the news stalwartly, but I later learned from her husband that she had left the appointment deeply shaken. She told her children that she had only one Christmas left. Her face was full of despair whenever I saw her. And yet Claire lived for nearly four years. She was able to travel, work part time, and take care of her children, but was unable to stop thinking that she could die at any moment.
Chastened, I tried a different approach. Henry Gold, a short-order cook in his sixties, had acute leukemia that had resisted all treatment. At one point, he asked me what else could be done. I reassured him that there were drugs that had not yet been tried, even though I knew they were unlikely to help. When Henry started to bleed around his lungs, I had the interns drain the hemorrhage with chest tubes; I insisted that he be intubated, supported on a respirator in the I.C.U., and given numerous blood transfusions. His heart developed a dangerous arrhythmia, so I gave orders for cardiac medications and electroshock. I never asked Henry what he wanted. He stayed alive for more than a week on the respirator, a catheter in his heart, tubes in his throat, unable to speak to family and friends who had come to his bedside.
On a chilly morning two days after our first meeting, Maxine returned to the clinic for her first round of chemotherapy. She had insisted on coming alone; Peter would pick her up afterward. The chemotherapy suite is a large, open space that holds twenty or so patients receiving intravenous drugs, some behind curtains, others talking or watching television. Maxine looked at the patients she passed. Most were wearing hats or kerchiefs to cover their bald heads. Several reclined in their chairs, thin and pale, too weak to sit up. It was clear that some of them would soon die.
A half hour after Maxine's chemotherapy treatment, Peter still had not arrived. Maxine's cell phone rang. "He's tied up," she explained to me, and we arranged for a car service to take her home. When I called Maxine later that evening to see how she was doing, Peter answered the phone and told me that she was sleeping.
"She's going to die, isn't she?" he said. He explained that he had been searching the Internet, and had read that in cases like Maxine's patients survived on average eighteen months, and that a remission lasted three to six months at best.
"Peter, as I said when we met, statistics don't tell you what is going to happen to any one person, just groups."
I got off the phone as quickly as I could. There could be no "back channel" discussions with friends or family; if Maxine had wanted to, she could have logged on to the Internet.
Over the next seven months, the metastases in Maxine's bones and in her liver decreased significantly. Although she was frequently tired and lost her hair, she was able to work part time, and even took a weekend trip to Manhattan with her parents and went to Newport for a friend's wedding. Then, on a routine visit at the end of May, after her eighth month of therapy, I noticed that one of her eyes wandered, and she seemed to be tilting her head to the right.
"Are you having any trouble seeing?"
She said that sometimes it was difficult to read.
"Any double vision?"
Yes, she said, on a few occasions that week, when she was walking down stairs.
Movement of the eyes is controlled by a set of cranial nerves at the base of the skull. An initial MRI scan of the brain did not turn up anything abnormal, but scans do not always detect small deposits on the cranial nerves. I explained that a spinal tap was the best way to determine if the cancer had spread to the brain; it would allow us to search for tumor cells in the spinal fluid.
Maxine lay on her side as a medical resident performed the procedure. I tried to distract her. We talked about the Red Sox, who had started the season strong, and whether, as usual, they would end up losing games in the homestretch. After sterilizing and anesthetizing the area between the fourth and fifth lumbar vertebrae, the resident passed a fine trocar into the spinal canal. Maxine twitched. Drops of fluid fell from the trocar into a test tube that he held under it. Normal spinal fluid is clear; Maxine's was cloudy.
"It's over," I said. "Stay down for an hour, so you don't get a headache."
She asked what it meant if the cancer had gone to her cranial nerves.
I was almost certain, based on the cloudiness of the spinal fluid, that this was the case. How much did Maxine want to know?
"It is a major setback," I said.
"I'm not sure I want to ask how long a remission lasts if the cancer is in my brain," she said.
"Are you sure you want to talk about this now?"
Maxine closed her eyes and nodded.
"People usually live several weeks to a few months without any treatment," I said. "But that represents the average. There are people who live longer. Treatment with radiation and chemotherapy instilled into the spinal fluid may or may not extend life, but it can reduce some of the most annoying complications, like the double vision."
Maxine was silent. "Is it even worth being treated?" she finally asked.
"You are the only one who can answer that question," I said. "If we don't treat it, it will quickly spread to other cranial nerves and parts of the brain and spinal cord. The quality of your life would be markedly impaired. I want to help sustain as much quality of life for as long as possible."
Maxine opened her eyes.
"I don't want to die," she said, beginning to sob. "I didn't think it would happen so fast, so soon. I'm not ready to die."
"I don't want to lose you," I said. There was nothing more I could say now that would help.
"Let's go step by step, and talk after the results from the spinal tap."
Later that day, I went to the pathology laboratory. Under the microscope, numerous large cells, with distorted nuclei, filled what should have been an empty field. "Carcinoma," the pathologist said.
Over the next few weeks, we began radiation treatment and a new round of chemotherapy, infused into her spinal fluid. At first, Maxine's double vision improved. But after three weeks or so she found that she couldn't move her left eye, and we put a patch over it. Shortly thereafter, the left side of her face began to droop. A second MRI showed that the cancer had spread to the membranes lining the cerebral cortex and spinal cord. It was evening when I came into Maxine's hospital room. She was watching television.
She turned to me as I switched off the TV.
"Peter left me."
I nodded, saying that I had noticed that he was not around the past few days.
"He's been seeing someone else the past three months."
I remained silent.
"I always felt, deep inside, that he was weak." Maxine paused. "No, not just weak. He's a schmuck. A real schmuck."
"Do you know what that word literally means in Yiddish?" I asked.
Maxine laughed.
I took her hand. She tried to press back, but had little force. The nerves from the cervical spinal cord were being compressed by the deposits of cancer.
"I'm not sure how much strength I have left," Maxine said. She was in a fragile condition. It was time to assess clinical issues.
"Remember once I asked you what your wishes were if we reached a point when further therapy would not improve the quality of your life?"
Maxine nodded. "So you think it's just a few days?" she asked. Her voice was hollow.
"Probably more than just a few days," I said. "Probably weeks. Or maybe longer--I've been wrong before."
"And really nothing can be done?"
Like all patients, Maxine was finding it almost impossible to give up hope.
"Nothing that I know of," I said. "And to continue to give you chemotherapy would not improve the time we have left. But anything I can do to make the time that we have left good for you, I'll do."
Maxine turned away. "How do I actually die from the cancer?"
"You lose consciousness, go into a coma, and either you stop breathing or your heart stops. But you're not aware of any of it."
She was silent as I sat holding her hand.
The first time I witnessed death was in my second year of medical school. My father had had a massive, unexpected heart attack, and I went to meet my mother at the hospital in Queens. The sheets were drenched with sweat. His eyes were filmy and repeatedly rolled upward. Coarse, grunting noises punctuated his breathing, and his chest heaved. His limbs jerked wildly. This went on for nearly half an hour, as a large clock on the wall ticked off the minutes. Then, after a last convulsion, a pink foam poured from his mouth, his head snapped back, the little color remaining in his skin drained away, and he was still.
I held my mother, numb with disbelief. The doctor on call, whom we did not know and who had stood by as we watched, closed the curtain around the bed. He looked at me holding my mother, and said weakly, "It's tough, kid."
Although I later learned that the flailing movements of my father's limbs were the result of neurological reflexes, and that he had not been conscious, I could not stop wondering if he had suffered. The ugliness of these final minutes often invades otherwise comforting memories of times we spent together. When I became a physician, I vowed that I would do everything I could to temper such gruesome experiences for the patient and for the family.
During the Middle Ages and the Renaissance, death was supposed to be met with words of welcome. This was the core of ars moriendi--"the art of dying." The "art" prepared and purified the person by linking his experience to Jesus' death on the Cross. Treatises like William Caxton's, printed in 1491, instructed laymen to think about the end of life, even when they were healthy, and dictated what words they should expect to hear and say when death was near:
"This time of your departing shall be better to you than the time of your birth, for now all sickness, sorrow, and trouble shall depart from you forever. Therefore be not aggrieved with your sickness and take it not with grutching but take it rather all by gladness."
Today, the physician frequently finds himself assuming a role that was once the exclusive province of religious authorities. Yet the palliative care he offers is primarily meant to ease physical suffering; he is not trained to alleviate emotional pain. In medical terms, a "good death" is a death with the least physical suffering possible. As ars moriendi suggests, though, there is a historical notion of a "good death" that is more complicated; it is as much about a cultivated attitude toward leaving life as it is about the physical act. Is there more, then, that physicians should do to make dying in a hospital after illness less emotionally taxing?
Last January, one of the first academic studies of how effectively oncologists communicate critical information to their patients was published. A hundred and eighteen patients cared for by nine oncologists participated in the research. The doctor-patient interactions were recorded on audiotape. The study tried to determine two things: whether the information disclosed to the patients was sufficient for them to make an informed decision about further treatment, and whether the doctor encouraged the patient's participation in choosing among treatments.
Although the oncologists knew that they were being taped, in more than a quarter of the consultations the patients were not told that their disease was incurable; a similar percentage were not informed of the side effects associated with the proposed anti-cancer therapy. Only five patients of the hundred and eighteen--some four per cent--received what the researchers considered adequate information. In nearly ninety per cent of the taped discussions, the oncologists failed to ask the patients if they understood the information being presented to them. These results are in keeping with prior research indicating that more than a third of patients with incurable metastatic cancer believe that the treatment offered by their doctors will actually cure them.
Suffering is not the only cost. Many in the medical profession have speculated that doctors' uncertainty in guiding patients through the end of life is one of the primary causes of rising health-care costs. More money is spent on care during the last weeks of life than on the months or years of care that precede it. The kinds of interventions that are routine in an intensive-care unit--pumps to sustain circulation, respirators to ventilate the lungs--cost hundreds of thousands of dollars. Some physicians don't want to acknowledge that a patient is going to die, and regularly order tests and procedures at a point when no reasonable gain can come of them. Studies show that a doctor does not shorten the life of the patient when he chooses to provide palliative rather than intensive care.
...[cut some parts]
After I talked with Maxine, I arranged for her to be transferred to a special hospice unit, and soon she began to drift in and out of consciousness. The cancer pressing on the cranial nerves connected to the back of her throat and her tongue had made it difficult for her to swallow. The nurses had to suction her saliva to prevent her from choking. Shortly before noon a week later, I was paged and told that Maxine's death appeared imminent.
Maxine's parents were sitting by her bed when I came in. They stood up, and Mrs. Barlow hugged me, crying. Mr. Barlow's face was frozen with grief.
Maxine was no longer conscious. Every few seconds, her chest heaved, and she gasped. She was entering what is called the agonal phase--taken from the Greek agon, which means struggle--a period that precedes death and can last from a few minutes to hours.
I warned Maxine's parents that this was usually harrowing, and that sometimes family members preferred not to witness it.
"I want to be with my baby," Maxine's mother said.
Maxine's hands began to twitch and her breathing moved into a syncopated pattern called Cheyne-Stokes, a short set of staccato breaths bracketing a long pause.
Mrs. Barlow raised her head.
"Maxie, we love you, and God loves you."
Mr. Barlow sat straight, his hands clasped in his lap.
Sometimes as a patient dies there is a convulsive burst of muscular activity, like a grand-mal seizure. I braced myself for it when Maxine's fingers began to twitch, as if she were grasping for an invisible object. These muscle contractions continued for some forty minutes. Then a harsh rattling sound came from her chest. I glanced at the nurse, who was next to the morphine infusion. There was a single explosive jerk of Maxine's body, a sharp arching of her chest, followed by a series of fluttering movements in the muscles of her neck.
The Barlows stood up. Maxine's skin was already changing to an ashen hue. I placed my stethoscope over her heart. "I am sorry," the nurse said. I reached over and took Mr. Barlow's hand, and then turned and embraced Mrs. Barlow as she cried.
I left the Barlows and went to the nurses' station to fill out Maxine's death certificate. I designated the primary cause as respiratory failure due to metastatic breast cancer to the brain and handed the chart with the death certificate to the floor clerk. The time of death was 12:57 P.M.
Source Citation:Groopman, Jerome. "DYING WORDS." The New Yorker 78.32 (Oct 28, 2002):
Sunday, January 13, 2008
NYT OpEd: "Sex and the Teenage Girl"
Sex and the Teenage Girl
By CAITLIN FLANAGAN
Published: January 13, 2008
Los Angeles
THE movie “Juno” is a fairy tale about a pregnant teenager who decides to have her baby, place it for adoption and then get on with her life. For the most part, the tone of the movie is comedic and jolly, but there is a moment when Juno tells her father about her condition, and he shakes his head in disappointment and says, “I thought you were the kind of girl who knew when to say when.”
Female viewers flinch when he says it, because his words lay bare the bitterly unfair truth of sexuality: female desire can bring with it a form of punishment no man can begin to imagine, and so it is one appetite women and girls must always regard with caution. Because Juno let her guard down and had a single sexual experience with a sweet, well-intentioned boy, she alone is left with this ordeal of sorrow and public shame.
In the movie, the moment passes. Juno finds a yuppie couple eager for a baby, and when the woman tries to entice her with the promise of an open adoption, the girl shakes her head adamantly: “Can’t we just kick it old school? I could just put the baby in a basket and send it your way. You know, like Moses in the reeds.”
It’s a hilarious moment, and the sentiment turns out to be genuine. The final scene of the movie shows Juno and her boyfriend returned to their carefree adolescence, the baby — safely in the hands of his rapturous and responsible new mother — all but forgotten. Because I’m old enough now that teenage movie characters evoke a primarily maternal response in me (my question during the film wasn’t “What would I do in that situation?” but “What would I do if my daughter were in that situation?”), the last scene brought tears to my eyes. To see a young daughter, faced with the terrible fact of a pregnancy, unscathed by it and completely her old self again was magical.
And that’s why “Juno” is a fairy tale. As any woman who has ever chosen (or been forced) to kick it old school can tell you, surrendering a baby whom you will never know comes with a steep and lifelong cost. Nor is an abortion psychologically or physically simple. It is an invasive and frightening procedure, and for some adolescent girls it constitutes part of their first gynecological exam. I know grown women who’ve wept bitterly after abortions, no matter how sound their decisions were. How much harder are these procedures for girls, whose moral and emotional universe is just taking shape?
Even the much-discussed pregnancy of 16-year-old Jamie Lynn Spears reveals the rudely unfair toll that a few minutes of pleasure can exact on a girl. The very fact that the gossip magazines are still debating the identity of the father proves again that the burden of sex is the woman’s to bear. He has a chance to maintain his privacy, but if she becomes pregnant by mistake, soon all the world will know.
Pregnancy robs a teenager of her girlhood. This stark fact is one reason girls used to be so carefully guarded and protected — in a system that at once limited their horizons and safeguarded them from devastating consequences. The feminist historian Joan Jacobs Brumberg has written that “however prudish and ‘uptight’ the Victorians were, our ancestors had a deep commitment to girls.”
We, too, have a deep commitment to girls, and ours centers not on protecting their chastity, but on supporting their ability to compete with boys, to be free — perhaps for the first time in history — from the restraints that kept women from achieving on the same level. Now we have to ask ourselves this question: Does the full enfranchisement of girls depend on their being sexually liberated? And if it does, can we somehow change or diminish among the very young the trauma of pregnancy, the occasional result of even safe sex?
Biology is destiny, and the brutally unfair outcome that adolescent sexuality can produce will never change. Twenty years ago, I taught high school in a town near New Orleans. There was a girls’ bathroom next to my classroom, which was more convenient for me than the faculty one on the other side of campus. In the last stall, carved deeply into the metal box reserved for used sanitary napkins, was the single word “Please.”
Whoever had written it had taken a long time; the word was etched so deeply into the metal that she must have worked on it over several days, hiding in there on hall passes or study breaks, desperate. I never knew who wrote it, or when, but I always knew exactly what that anonymous girl meant. When I looked out over the girls moving through the hallways between classes, I wondered if she was among them, and I hoped that her prayer had been answered.
Caitlin Flanagan, the author of “To Hell With All That,” is working on a book about the emotional lives of pubescent girls.
By CAITLIN FLANAGAN
Published: January 13, 2008
Los Angeles
THE movie “Juno” is a fairy tale about a pregnant teenager who decides to have her baby, place it for adoption and then get on with her life. For the most part, the tone of the movie is comedic and jolly, but there is a moment when Juno tells her father about her condition, and he shakes his head in disappointment and says, “I thought you were the kind of girl who knew when to say when.”
Female viewers flinch when he says it, because his words lay bare the bitterly unfair truth of sexuality: female desire can bring with it a form of punishment no man can begin to imagine, and so it is one appetite women and girls must always regard with caution. Because Juno let her guard down and had a single sexual experience with a sweet, well-intentioned boy, she alone is left with this ordeal of sorrow and public shame.
In the movie, the moment passes. Juno finds a yuppie couple eager for a baby, and when the woman tries to entice her with the promise of an open adoption, the girl shakes her head adamantly: “Can’t we just kick it old school? I could just put the baby in a basket and send it your way. You know, like Moses in the reeds.”
It’s a hilarious moment, and the sentiment turns out to be genuine. The final scene of the movie shows Juno and her boyfriend returned to their carefree adolescence, the baby — safely in the hands of his rapturous and responsible new mother — all but forgotten. Because I’m old enough now that teenage movie characters evoke a primarily maternal response in me (my question during the film wasn’t “What would I do in that situation?” but “What would I do if my daughter were in that situation?”), the last scene brought tears to my eyes. To see a young daughter, faced with the terrible fact of a pregnancy, unscathed by it and completely her old self again was magical.
And that’s why “Juno” is a fairy tale. As any woman who has ever chosen (or been forced) to kick it old school can tell you, surrendering a baby whom you will never know comes with a steep and lifelong cost. Nor is an abortion psychologically or physically simple. It is an invasive and frightening procedure, and for some adolescent girls it constitutes part of their first gynecological exam. I know grown women who’ve wept bitterly after abortions, no matter how sound their decisions were. How much harder are these procedures for girls, whose moral and emotional universe is just taking shape?
Even the much-discussed pregnancy of 16-year-old Jamie Lynn Spears reveals the rudely unfair toll that a few minutes of pleasure can exact on a girl. The very fact that the gossip magazines are still debating the identity of the father proves again that the burden of sex is the woman’s to bear. He has a chance to maintain his privacy, but if she becomes pregnant by mistake, soon all the world will know.
Pregnancy robs a teenager of her girlhood. This stark fact is one reason girls used to be so carefully guarded and protected — in a system that at once limited their horizons and safeguarded them from devastating consequences. The feminist historian Joan Jacobs Brumberg has written that “however prudish and ‘uptight’ the Victorians were, our ancestors had a deep commitment to girls.”
We, too, have a deep commitment to girls, and ours centers not on protecting their chastity, but on supporting their ability to compete with boys, to be free — perhaps for the first time in history — from the restraints that kept women from achieving on the same level. Now we have to ask ourselves this question: Does the full enfranchisement of girls depend on their being sexually liberated? And if it does, can we somehow change or diminish among the very young the trauma of pregnancy, the occasional result of even safe sex?
Biology is destiny, and the brutally unfair outcome that adolescent sexuality can produce will never change. Twenty years ago, I taught high school in a town near New Orleans. There was a girls’ bathroom next to my classroom, which was more convenient for me than the faculty one on the other side of campus. In the last stall, carved deeply into the metal box reserved for used sanitary napkins, was the single word “Please.”
Whoever had written it had taken a long time; the word was etched so deeply into the metal that she must have worked on it over several days, hiding in there on hall passes or study breaks, desperate. I never knew who wrote it, or when, but I always knew exactly what that anonymous girl meant. When I looked out over the girls moving through the hallways between classes, I wondered if she was among them, and I hoped that her prayer had been answered.
Caitlin Flanagan, the author of “To Hell With All That,” is working on a book about the emotional lives of pubescent girls.
Thursday, January 03, 2008
Eggs and Sperm
Coming to school at 8 am was like waking up with a massive vacation hangover.
The MS2's are definitely more focused after winter break, since we take the boards in late March to early April. Juggling our new block (reproduction and development) with Boards studying will be interesting, but co-productive, so it's not so bad.
Haven't exactly climbed back onto the MedSchool Horse, stayed home an extra day to watch my brother march in the Rose Parade and celebrate my dad's "real" birthday (long story). Didn't have my syllabus or any idea what was going on (not like that's abnormal).
On a brighter note, my First Aid 2008 arrived in the mail today. It's like getting a new Britney Spear's album; it's that exciting! Tao Le, the senior editor of First Aid, was actually a UCSF med alumnus AND a former editor of Synapse! :)
However, I haven't actually opened First Aid yet...or ever...and it's becoming apparent that one of the biggest challenges to studying for Boards is not drowning in a sea of semi-useless board review books. Still have no clue what's going on.
But, hey, that's okay. Today during histology lab, we had a mystery case concerning a female patient who had amenorrhea and hirsutism. The question asked, "what was her diagnosis?"
My lab partner, Nick, (bless his heart), thought very solemnly for a minute before carefully writing down in his lab syllabus: "No...Egg...Syndrome."
The MS2's are definitely more focused after winter break, since we take the boards in late March to early April. Juggling our new block (reproduction and development) with Boards studying will be interesting, but co-productive, so it's not so bad.
Haven't exactly climbed back onto the MedSchool Horse, stayed home an extra day to watch my brother march in the Rose Parade and celebrate my dad's "real" birthday (long story). Didn't have my syllabus or any idea what was going on (not like that's abnormal).
On a brighter note, my First Aid 2008 arrived in the mail today. It's like getting a new Britney Spear's album; it's that exciting! Tao Le, the senior editor of First Aid, was actually a UCSF med alumnus AND a former editor of Synapse! :)
However, I haven't actually opened First Aid yet...or ever...and it's becoming apparent that one of the biggest challenges to studying for Boards is not drowning in a sea of semi-useless board review books. Still have no clue what's going on.
But, hey, that's okay. Today during histology lab, we had a mystery case concerning a female patient who had amenorrhea and hirsutism. The question asked, "what was her diagnosis?"
My lab partner, Nick, (bless his heart), thought very solemnly for a minute before carefully writing down in his lab syllabus: "No...Egg...Syndrome."
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