Insulin and Eugenics... I am upset. This is a rant.

As a type 1 diabetic, I am often very angry. Usually this is secondary to hypoglycemia or an ability to eat something because I inadvertently left my insulin at home.

But today I am upset because I am running out of insulin and I only have $600 left in student loans until late February. Why is this a problem? Because as someone with good medical insurance, my doctors have always prescribed me humalog and lantus, which are bloody expensive without a prescription (and are actually still really expensive with a prescription and insurance: $50 each for what I need in a month). But as a medical student I don't have time to go see a doctor to get a prescription to get my bloody f***ing insulin. I am really upset because as I speak I have about enough humalog (lispro, short-acting insulin) to get me through to Monday, after which I guess I'll start employing a poor man's metformin: large amounts of acetaminophen and straight hard liquor. Your liver transaminases skyrocket, but you've effectively bludgeoned your body's best organ so badly that it stops going through with gluconeogenesis. Oh, and a ton of aerobic exercise makes your body more sensitive to the effects of lantus (glargine, long-acting insulin), so I guess I can look forward to dropping a few pant sizes and... cirrhosis. Lots of preventable, freaking cirrhosis.

I don't know what I'm supposed to do. There must be type 1's who are busier than me and have less time to see doctors. And I know there are type 1's who don't have health insurance because this country is absolutely terrible. So how can I get insulin at a reasonable price without having to see a doctor? Because, honestly, I've had diabetes for over ten years and I know my body's personalized ways of dealing with this disease in a way that literally no other health professional could understand. I know the tricks. I know the secrets of my metabolism. My A1c is always under 7.0 and my hypoglycemic events are now well controlled. I know what I'm doing.

SIDENOTE... no wait, MAIN POINT: I think it is absolute bullshit that people need prescriptions for something that their body erroneously stopped producing. Almost everyone else around me is making insulin, but just because my body f***ed up when I was thirteen, I have to spend thousands of dollars on a month's worth of high quality insulin? What kind of justice is that? Answer: it's not. It's wrong. It's condemning people to a constant economical disadvantage on top of the disease they've contracted who's co-morbidities will likely kill them if they don't control the aforementioned disease. In a country where medications aren't regulated to make them fairly priced (hell, I think they should be bloody f***ing free but I realize I'm incredibly biased) and health insurance is severely limited, we are essentially killing off diabetics. I realize that many type 1 diabetics can make it to reproductive age without dying first, but I've seen a 24 year old diabetic with f***ing gastroparesis--that's really severe neuropathy. And now that I've gone through OB-GYN, it becomes apparent that type 1 diabetics with A1c's of 13.6, like this 24 year old, would never be able to carry a healthy child to term. She will likely never produce any children because why? Because our health system is unjust? What sick kind of world is this?

And you know what's worse? The type 1 diabetic population that is under insured and hurting the most is minorities, specifically blacks. And you know what's f***ing insane about that? DIABETES IN AFRICAN POPULATIONS HAS NO DISCERNABLE GENETIC COMPONENT. Whereas caucasian type 1 diabetics usually have some weird HLA inherited predisposition sh*t. And yet, at least in Chicago, those people will be preferentially allowed to live with a disease that could be greatly reduced within the human population if only they were put to the slow and painful death that awaits most uninsured type 1 diabetics.



[edit]: Okay. So I calmed down a little bit. Let me just say that I recognize that a lot of white people don't have health insurance either. But at least in Chicago, economics and race are obnoxiously linked in a way that has already started to upset my psyche. So I'm sorry about that. The truth is, all type 1 diabetics are in an equally unfortunate place in a society where close health maintenance is ludicrously expensive.

And also, I don't think I do a good job of separating my emotion's from the job. Especially other type 1 diabetics so far along. Seeing another black, 24-year-old, type 1 diabetic, laying on a bed in the emergency department, clutching at her stomach and moaning for morphine, secondary to gastroparesis and then her resultant addiction to painkillers, really upset me I guess. I want to help them but I know that it's literally too late because you don't recover from severe autonomic neuropathy. You just suffer until you die. From something completely preventable.

I guess this whole thing bothers me, not just because on the whole diabetics are treated very poorly, but because I'm now a healthcare professional, and I am surrounded by physicians every day, but I don't think I can just ask them to write me a prescription for insulin because I'd rather go to work than call the doctor's office to set up an appointment, then call the dean of student affairs (another physician), and then the clerkship director (also a physician), and then drive to god knows where for a fifteen minute conversation with the doctor to write me a prescription so I can save $350 for something that almost everyone in the world doesn't think about.

It's upsetting. If I had my way, everyone with a type of medical/biochemical deficiency would be able to get whatever they need for next to nothing because that's what equality is. Hypothyroid? You get thyroxine, no problem. Chronically depressed? We'll get you an SSRI or maybe even some SNRI's if you're lucky and need more norepinephrine. Diabetic? We'll get you all the insulin you want. Because giving you anything less than that is a crime.




So this is where I read that Diabetes in blacks and asians is often idiopathic: http://www.aafp.org/afp/1998/1015/p1355.html
Although since I am both caucasian and african, I won't know if I have the idiopathic form until either A) my entire genome gets sequenced (I hear it's only $1000 now!) or B) they look for islet cell antibodies in my serum.

A Slave to One's Emotions

On a recent episode of The Daily Show with Jon Stewart, the guest was Michael Fassbender and he talked about his experience on the set of "12 Years a Slave." It's apparently an intensely emotional and raw movie adaptation to an actual book written by an actual person in the 1800s. Fassbender, who is hella white, plays a supporting role as the incredibly cruel plantation and slave owner. Of this experience, and how he dealt with having to pretend to be a terrible person for most of his days, he said this:

"I mean especially when you're dealing with such heavy material it's nice and necessary sometimes to have light moments in between so it doesn't become all the time heavy and you get [blinded]....
so the moments you can find relief and respite you do, and other times that require it, you stay in the moment as it were."

I think this quote describes how I deal with working in hospitals. You're surrounded by so much of what is disgusting with humanity: pain, deception, corruption, death; so much unabated suffering. On the one hand, I'd like to live in the moment and experience the pain my patients suffer with them. But on the other hand, if I did that with everyone in the hospital, I'd be so drained every day that I don't know if I could function. Both of my parents are hilarious--albeit in different ways (one's abstract, surreal humor; the other's just dark and sarcastic)--maybe that's the only way they survived medicine for the decades they sacrificed to it. 

But on the other hand, I'd like to feel with my patients so that I never stop working for them. When I turn patient's into little anecdotes, I stop caring for them. When I just stare at their assessment statement and their labs, I forget that they are people who may lighten if I go talk to them, who may benefit when I hold their hand. 

What's Death Got to Do With It?

I realized something today while I was hypoglycemic at 63 mg/dL and more susceptible to fear: I am absolutely terrified of death. Not that that is something new. When I was nine I watched a movie about time travel while vacationing around Mesa Verde, and I realized, at nine, that one day I would die and all my accomplishments would account for naught. More than that, I realized that an eternity of total, unyielding unconsciousness was something I never wanted to experience but something I one day would. I, personally, do not want to die. Besides the fact that I engage in a lot of moderate risk behaviors, I do not want to die. I have been suicidal twice in my life, and those events were partially fueled by untreated depression, but they were mostly fueled by my previous realization that one day I will die and everything about me will mean nothing. 

Besides the soul-crushing nihilism surrounding my personal future death, I am also reaching the age where the people I know and love are starting to die. Yet still these deaths are mostly accidental… I feel a great amount of guilt for the deaths of people close to me… those that have stolen people who are related to me by blood in particular… but I cannot change what I did, and ultimately, even though I failed to do things that may have prevented their deaths, their lives were not my responsibility*. 

Now that I am in medicine, lives are very much my responsibility. I have a feeling that this is the source of my fear. I have always been a very good liar. I sometimes attribute this to the fact that I am a natural fiction writer, and therefore I am more readily capable of producing fictional realities in my mind. But the reason why I lied when I was little, and the reason why I occasionally lie now at the age of 24 is because I do not want to let someone down… I do not want to fail.

As a result, when I encounter a patient-doctor situation where the patient might be dead, I run back to my resident and make up reasons for not seeing the patient. I have two examples of this behavior:

The first example occurred when I was asked by my team to inform a suicidal patient that he wouldn't be able to leave the hospital until he was admitted by psych and evaluated for several days. I went to the patient's room and found it empty… But all suicidal ideationists have to have a 1 to 1 sitter, someone with them at all times…. yet here was a hospital room completely devoid of people…. although the bathroom light was on… and it occurred to me that this patient of ours may have hung himself on the water line that connects to the shower head… or cut open his veins, letting the blood pool out from around his wrists, only to let is fall on the brown tiles that constitute our hospitals bathroom floors. WHAT I WISH I COULD HAVE DONE would have involved knocking on the door, and upon not hearing a response from its occupant, opening the bathroom door to see if any dead bodies were mucking around. If a dead person had been found, I surmise I would have run out into the hallway and yelled "HELP", forgetting how to present patients to healthcare professionals.

The second occasion involved a patient with chronic hypotension. My intern instructed that I run to check the patient out--ask about dizziness, measure blood pressure, assess any changes in mental status--but when I got to the room the patient was fairly unarousable… he was asleep. I knocked several times on the door to this room and on the walls containing him. I even yelled out his name. Yet he did not even twitch underneath his sheets. The next step in arousing a patient would be to apply a sternal rub--basically pounding on somebody's chest with your fingertips. But I couldn't bring myself to touch this patient… what if he was really dead? He wouldn't respond to my tapping. He wouldn't be saved no matter what medical interventions were applied to him.

In both of these situations, the patient was found to be very much alive. I was acting inefficiently when I decided to enter the patient's room only to promptly leave it when I didn't get the response I wanted. 

The death of a patient seems like the greatest insult to a physician, even scoring above having your medical license removed. It tells you that you missed something. Hell, we have M&M's specifically designed to analyzed where you as a physician failed the patient.

I don't want to tell someone a patient died because we didn't check their blood pressures often enough. I would rather lie than experience that shame and guilt.

Rules and Regulations: Is Cover-Your-Ass Medicine Devaluing Healthcare?

Today was the day I realized I will have to go into family medicine. Not because I loathe internal medicine (quite the opposite--I have loved almost every day of this clerkship) but because I cannot work inside a hospital. There are many terrible things about hospitals. They are full of sick people. And because they are full of sick people they are always full of the things that accompany sick people in societies both full of resources and those that reside in the third world: the smell of disinfectant mixed with the odor of bodily excrement--almost unavoidable if you spend a day walking around on the floors; the screams... the tortured moans of patient's suffering either from a psychiatric issue (although who wouldn't be driven insane by being locked up in a hospital room for days?) or a pressing physical complaint? (I don't imagine a leg ulcer infested with maggots* can be purified without any amount of pain).

But, unfortunately... well, unfortunate for those people who find themselves confined to hospitals, and also for those people like me who have the option of working in one... the worst thing about hospitals isn't the patients or their illnesses. The worst thing about hospitals are their dumb-@$% rules.

I have a patient. He is my only patient. He is my favorite patient. He is super old and he has borderline dementia.... he reminds me of my father and so I try to be super nice to him because he, like my father in about a decade, deserves the best.

One of the things that is really hard to deal with while working as a pretend internist is how old and close to death so many of our patients are. In surgery, all of our patients had to be surgical candidates, and to be a surgical candidate you have to be able to withstand general anesthesia and someone poking around your insides. This is not so with internal medicine. Hell... one of our team's patients died the other day.

SIDE NOTE: I think surgeon's fear death way more than other physicians. While m&m's (morbidity and mortality) presentations for internal medicine (IM) are relatively tame and emotionally controlled, surgery m&m's seem to be intensely discussed, with the accusations of "who-to-blame" are hotly debated. I think this is a result of surgeon's wanting to, one some level, think of themselves as able to prevent death in their patients. I think this also makes much more timid, surprisingly, when it comes to patient care. I called both of my parents today (remember: both of my parents are surgeons) to ask them what they would have done with one of our patients: patient is an 84 year old man, with a past medical history significant for hypertension, diabetes, and two previous strokes, who was admitted to the hospital 7 days ago with slurred speech and left sided facial weakness suggestive of acute, focal cerebral ischemia, with brain CT and MRI also suggesting stroke, who know, the day before being cleared for discharge, has spiked a WBC count. Both of my parents said he should stay in the hospital. True, you should find the source of his infection. But we could almost be sure what the infection was... couldn't we just treat him for that and send him on his way? The extra care my parents seemed willing to offer might have simply been an artifact from how much more surgeons have to pay in medical malpractice. OR, they could simply hate seeing patients die from something so insidious and so simple as an infection. 

Where was I...? Yes, the incredibly stupid rules. And I'm not complaining about stupid seeming rules that are set up for the purpose of patient safety. For example, this patient, with his borderline dementia, was put on high fall precautions... essentially, he was strapped to his bed by soft handcuffs, which are called "soft restraints" in medical jargon. I understand this rule--if he falls out of bed he could easily die--although it is terrifying to think of fading in and out of orientation to a world in which you are permanently tied up against your will. No. I hate rules like the one that requires the next of kin to physically enter the hospital to sign cover-your-ass paperwork when the patient isn't at full decisional capacity. And even though a lot of terrible malpractice cases, a lot of morbidity, and a lot of mortality have arisen from the fact that things weren't explained well enough to the patient, there are some procedures that are so non-lethal it really doesn't make sense to require the patient's family member(s) to come in. Some people are busy. Most people are busy. Even I never get a weekday off work... if I was told I had to go to the hospital on a Wednesday to fill something out so that my parents could get discharged... I'd probably still take until the weekend to scrounge up enough time to liberate my parents. Doctors know what's best for the patient. We shouldn't have to explain to the patient how the procedure is done, what risks are involved... if the risks are minimal enough.

I know, I know: that wreaks of paternalism. But in all honesty, what we do now is highly inefficient. If I become an internal medicine resident, I'm going to spend my intern year writing down all the times money and/or time was wasted because we had to get paperwork down before patients could get what they needed and leave the hospital as soon as possible. Some patients love staying in the hospital... most patients don't. All doctors want to see their patients get back to baseline so that they can be discharged. But I don't think enough doctors want to put in the time necessary for analyzing why these rules and regulations are often detrimental.

Or maybe we just don't have the time. After all, I rarely see doctors taking off weekdays.

*yes. there were actual maggots in this patient's room. there were actual maggots under her skin. however, when they were finally discovered and the wound care nurse and her assistants were telling everyone outside the room about their findings within, I did not--in that moment--have enough courage to walk inside and look that hollering woman in her face while examining her wounds. I was not brave enough to examine and deduce what exact parts of her scabbed up wounds were flesh and blood and what were maggots.

Clerkship

I hate my life.

But first, let's focus on the positives:

• During my last entry, I had decided (although not revealed) that I was going to push my step one test date back 10 days to June 11th. Good news, I passed. 
• I am now almost entirely moved into my downtown apartment. My room is still full of random stuff and I still don't have a well stocked fridge, but I know the area pretty well now and every weekend I go to the beach (within walking distance) with my friends. 

Okay, now on to clerkships.

I started with Surgery. At Lutheran. Widely rumored to be the toughest place to do a surgery rotation. Results are in: I hate it even though I love how much I'm learning and how much I'm doing everyday. In the last two-and-a-half weeks I have cried six times, every single time because of surgery. I am a mess. And I finally know exactly why so I'll tell you:

Being a third year medical student on rotations is like being a middle child: no one likes you and no one pays attention to you so you might as well die. 

If we were to compare the classical hierarchy of teaching hospitals to a nuclear American family circa 1950, the Attendings would be your parents, your older sibling is the residents, medical students are the middle child, and depending on group dynamics, the role of younger sibling is played by either medical students who are great at sucking up and being professional or interns. 

Attendings are the people you want to be like. They are your role models. Sometimes you hate them, but most of the time you love/respect them. They may make you upset because they yell at you and occasionally call you dumb, but eventually you realize they are right about almost everything. 

Residents are your older sibling. But there are a lot of different ways older siblings can act:

-We're in this together: Life is hard. But with any luck, your older sibling likes you and wants you to succeed. This sibling gets extra points if they know how to succeed. Residents can be good role models, just like attendings, but they can also be terrible influences. And as a young med student, you can't really know what's right or what's wrong yet. So you just pray these people are good influences.

-Too cool for you: Okay, you can't really blame someone for this, and to be honest, medical students are dorks. So...

-Constantly antagonistic: For some unknown reason, most likely being they are still bitter about that you took attention away from them (i.e., your birth), they hate you. They would never say that. But if they can, they will make you look bad. For fun. Because, to sum it all up, the world is cruel and if seeing someone else suffers helps you get through your shift, then someone's going to suffer. 

Essentially, residents will determine how you feel about yourself day after day. Your parents may be important to you, but sometimes, they just don't understand. If a resident physician tells you that you did something well, then you feel pretty cool and competent. Otherwise you're just a useless person who know one pays any attention to.

Finally, there are the suck-up med students, the little sibling who really just makes you feel worthless. Everyone is so much nicer to them for reasons you cannot completely elucidate. They are even nice to you--but only some times. At other times they are totally working the angle so they get more assignments. Everyone wants to be around them... nobody wants to be around you. 

Anyway, I'll probably post up something less... emotional, more analytical later. But right now, an hour past my bedtime, I'm genuinely shocked that I haven't quit yet. 

More good news I guess.

Thalassic

Thalassic is defined as "of or relating to the sea." Thalassemias are hematological conditions in which you don't produce adequate amounts of certain proteins that compose your hemoglobin (the stuff that carries oxygen around on your RBCs).

The name for this condition comes from the prevalence of this condition around the Mediterranean Sea, essentially: you live around a sea and your blood is messed up. However, another translation of Thalassemia would be something like.... "Blood full of the sea" or "Sea Blood" which sounds to me like the exact opposite of Land Lubber. I love it.

Unfortunately, there is a wide spectrum of how severe a thalassemia can be: from clinically silent to death in utero. 

Gender Discrepancies (I/II)

Did you know women and men are actually quite similar? We really are. If we were all raised in a society that interacted with the two genders in the exact same way, we'd probably end up like some gender-neutralized weird race of alien a la Star Trek: The Next Generation. We'd still have the two separate sexes, but we probably wouldn't have this weird, polarized, gender dichotomy. The terms tomboys and janegirls, for example, would no longer make sense and be cast aside like the frivolous trash they are.

Yesterday, in our community groups (which is basically a quarter of our class plus one practicing physician from the surrounding area), we were asked to talk about American health care. We were asked vague questions by our community leader and what ensued was kind of hilarious and also pretty depressing.

On a side note: I talked entirely way too much, which is unfortunate because I hate people who act the way I acted yesterday in class. I will have to implement a more stringent foot-in-mouth policy for any future large discussion groups. I am also a crazy liberal. I need to stop telling people I'm a moderate since I clearly believe that taxes are necessary and the government should govern our personal liberties as little as possible (but I still think we should all have access to affordable health care because it should be a personal liberty).

There were a lot of nuances in our overall debate--this is to be expected since if we could formulate a clear solution to the health care problem in an hour and a half, than our government, as crappy as it is, would already be enacting such solutions as policies nationwide. But in the end, clumping all the nuances together and then defenestrating them because who actually gives a **** about nuances?--there were only two general positions a person could have: you believe Universal Health Care should be guaranteed for everyone or you believe that Health Care should be payed for by individuals in some way outside of paying taxes.

Good points can be made for either side, but as you recall, I threw all those nuances out the window, and it seemed for the most part that the most avid supporters of the opposing sides were also of opposing genders. Universal health care is somehow more appealing to more women than it is to men.

Although clarifying point: my sample size was quite small (n=48) and it wasn't as if no men liked the idea of universal health care. Some favored it. Also, not everyone talked so the real sample size is closer to around 20. So I might just be making up a ton of crap, in which case, I'm sorry if the following is just super offensive. 

I am trying to figure out why that is. Last year when I went to the American Medical Women's Association's National Conference in Miami, the keynote speaker kept commenting on how women are dearly needed in the medical field because women are natural healers and we just care more. It was pretty inspiring but it seemed kind of hurtful to the small amount of dudes I knew who are actually pretty loving people. But now that I think about it, do I actually know any guys who are selfless? Or are they just decent human beings who have yet to have their selflessness tested? How selfless are they, really? Because I don't think caring is quite enough. I care a lot about things but don't actually do anything about it because I am selfish. I really care about making sure people understand that America's  oppressed groups aren't all good to go now that we've slapped band-aids--Title IX and Affirmative Action--on the gaping wound that is injustice. But all I actually do is update my status on Facebook, maybe including a link to a blog article or a recent study.

But when I think about selflessness more, I realize a better question may be: do I know anyone who is selfless? 
Not many.
Well, that's depressing, seeing as I am in Medical School. But I guess everyone isn't being "selfish" per se, just too busy studying so that they can one day be selfless. <<>> This seems too nuanced. I will stop ruminating. 

If we just assume women care more, why is that so? Is it because we have the capacity to become mothers? Because men have the capacity to become fathers, which I have been assured can also be a full time job. Both of my parents were full time Surgeons, and I am sure they both cared about me equally, but I saw my mom much more than I saw my dad, so can we assume my mother was more selfless than my father? I think that is a far argument. Although we will never know for sure because my dad may have thought that by working longer hours, he would be able to give us more opportunities with the money he'd make, and to him, that would seem like a more valuable pursuit than teaching us how to tie our shoes. My dad may have been selfless. Conversely, my mother may have spent more time with us to show the world that she was not only capable of being a woman and a surgeon, but also a loving mother. My mom may have been selfish.

But either way, actions speak louder than words, and I saw my mom more than I saw my dad, even though they had similar jobs. I think this behavior must be socialized, because my mom didn't actually need to spend so much time with us. We could have just had babysitters who stayed at our house longer.

 Now that I've dragged you through my own internal thought process, let me actually tell you facts: female physicians make $17,000-a-year less than male physicians, on average, for doing the exact same amount of work. This number has been normalized, so any arguments that male physicians tend to work longer hours (as was the case for my parents) or that male and female physicians choose to enter different specialties or practice in different locations (as was not the case for my parents) does not at all affect the statistic that women make $17,000 a year less than men for doing the exact same work. Discrimination, of course, plays a role in this inequality, but another interesting point that the researchers brought up was that some of the blame actually falls on women: women will stop negotiating their wages with their employers at a lower rate than their male counterparts. You could see this as women having a lower innate self-worth (which is true in society overall but may not apply to physicians) or you could see this as women willing to do more "caring" for less economic compensation. That sounds a lot like selflessness to me.

.... Shelf!

Surprise! I have a giant subject exam next Wednesday! I'm terrified! Hence the exclamation points!

I'm terrified because it will be worth 20% of my final grade in my favorite class: Clinical Neuroscience. I had a feeling I'd like psychiatry even when I came to medical school, but it was never something I thought I'd seriously like.

I came in with a pledge to make medicine easier to understand for my patients. I fully believe I will have to see a lot of patients, but I want to make every single one of them feel in control of their health--by giving them the information and the support they need to make their own decisions.

This is why my final research project in college involved looking at the ways doctors communicate with their patients.

And psychiatry, I realize, sets itself up as the specialty that requires communication over everything else. Even with primary care--let's say family medicine, which is still my first love--you talk with the patient, and most of the time, talking is all you need. But you still approach a patient in primary care as an algorithm. History fills in some information, labs and tests fills in the rest. You shake it up, and you come up with a diagnosis. Or several diagnoses.

Psychiatry at the very start basically says: the only way you're going to get anything done is communication. There is no back up plan. You can't be that doctor who is really smart but also really distant--really bad at talking to people. I guess what I like most about psychiatry is that it really emphasizes medicine as an art form.

Regardless, I am now considering a double residency because hey--I'm young. But what I really want to do is qualify for an Honors Elective in Child Psychiatry. That was the most ... electrifying part of this course for me. Many of my friends, I realized, had these conditions. Most memorably, my best friend in elementary school had selective mutism. Which I always thought was interesting as a little kid, but now I understand it and I find it even more interesting.

Anyway, to qualify for the Honors elective I need an A in clinical neuroscience. And right now, without any extra credit, I have an 85%. SO FAR AND YET SO CLOSE. So, the next 6 days of my life will probably be panic, panic, panic.

Adding pain to misery, 50-55% of the exam is on "Central and Peripheral Nervous System" which is incredibly vague. Fortunately, the vagueness was removed by the course director who basically explained this chunk of questions as focusing on... you could easily guess it... my least favorite and, I am not exaggerating this when I say, my most personally antagonizing part of medical education... Neuroanatomy!

Trials and tribulations, right?

Here's to a weekend of staring at brains!

Board Review Tuesdays (CramFighter)

Fact: I am "getting serious" with USMLE Step 1 (Boards) studying.
Fact: I am attempting to have a weekly segment discussing various USMLE Step 1 topics.
Fact: I am starting that segment today.
Fact: That segment will be called Board Review Tuesdays.
Fact: That segment is this segment, and I'll start to talk about boards right now.

I stumbled onto CramFighter at around 4 in the morning during winter break, waking up in a panic, realizing that I would be taking the boards in less than half a year. But CramFighter is actually amazing, not just an impotent comfort against the waves of panic attacks that now assault me on a fairly regular basis. It's incredibly comprehensive, it's stylish (rockwell font in the logo, I'm pretty sure), it's simple, and it does what I cannot do: It makes a definitive time-line of what to study.

Well, almost definitive. You can change the schedule at any time by clicking on the "edit schedule" button. And I've been switching my scheduling a lot. I originally decided to read 18 review books in total, do 2185 UWorld questions, and look over 100s (read: 200) of flashcards for pharmacology and microbiology. This would later prove to fail.

But the CramFighter approach is very helpful for people who are preparing for the boards not through on-line or in-person classes, but through reading. It has proven incredibly helpful for me, in that I've actually studied for the boards instead of opening up First Aid and then promptly closing it, putting it aside for tomorrow, eating dinner, and going to sleep.

Ah yes, CramFighter is amazing. But it's not definitive. You can change it at any time, editing your schedule in the following ways:

• Learning Resources you want to use (text books, review books, flash cards, practice questions)
• Time you want to spend each day of the week reviewing
• Order in which you review topics (both systems based and course based)
• this is actually its best feature: it can scavenge for topics in the various review books you own so that you end up reading, say, all you have on psychiatry at the same time
• Days you want to take off (holidays, catch-up days)

So I started off with 18 review books, 2185 Uworld questions, and about 450 flashcards. This proved unsustainable: I was going to end up reading over 70 pages per day and doing about 100 practice questions a week. 

That's terrifying. And after only successfully completing my readings 4 out of about 15 days (and cheating crassly) I decided to remove all my Board Review Series books, 7 in total. Now CramFighter is telling me to read about 30-50 pages per day, which is much kinder to my psyche.  And actually manageable.

Although I want someone to appreciate the fact that I will be spending 2 hours every day on nothing other than preparing for an exam I will take four months from now. 

Pros: Plans my "life" for me, keeps all my books in order, helps me study in the most efficient way possible, knows my name (see above: Hi, Elora!) and seems excited that I exist

Cons: The full version costs $7.99 a month (I'm just going to assume online study/review courses are much more expensive), there is no extrinsic motivation (although most medical students seem to have intrinsic motivation down). 

Overall Impression: They should make this for other large exams, like the Bar. I have no idea how law school works, but I can only assume something like this would be helpful for all major exams that are terrifying and include literally every little detail on an entire field of academia. 

And That's Delirium!

Recently I found out that hypoglycemia can precipitate the mental state of delirium. As a well controlled diabetic, I have a lot of hypoglycemic events, so I am versed in the various physiological and psychological events that coincide with a drop in blood sugar. However, the number of times I've been delirious because of hypoglycemia? It's hard to say--I only just discovered what delirium is (thanks clinical neuroscience!)

But I'm going to say I've been completely incapacitated by delirium secondary to hypoglycemia twice: once in the central rain forests of Costa Rica, and once again in the sixth row of Finch Auditorium at Rosalind Franklin University.

The first time--in Costa Rica, was innocent enough. I had lost a lot of weight rather precipitously. The temperature was always in the low eighties and I had to hike about ten miles everyday under the weight of climbing harnesses, bio-tags, poorly prepared, non-Skippy peanut butter sandwiches, and gallons and gallons of water. Regardless, when I returned to the states briefly to take the MCAT, I sidetracked and took a shopping trip to the Gap, only to realize I was a size four, which means I probably weighed about one-hundred-and-forty-five-pounds, placing my BMI at 20. Although still in the normal range, when you consider my amazing, incapable-of-becoming-osteoporotic bones, a BMI of 20 is deadly. Or at least deadly for a diabetic since I didn't have any excess stores of glycogen in my liver. All hypoglycemic events had to be dealt with by myself--not the glucagon my diabetic body was still capable of making.

Essentially this just meant waking up with hypoglycemia frequently and having to drink more gatorade. But one morning, I woke up with a huge existential crisis hovering around my incapacitated body. I will never know how low my blood sugar was--all I remember is that my roommates had already left for breakfast and I found myself alone in the jungle, surrounded by the creaks and caws and chirps of forest dwellers and the hot and sticky and humid air of the tropics. Oh yes, and an existential crisis.

There was a journal by my bed. I wasn't really recording much in it: we had actual journals to take down actual data--like the types of epiphytes on the branches held up by the forty meter tall trees we climbed. I had a journal to take down various soil measurements (soil is so cool! But that is neither hither nor thither). But by my bed was a journal of just short little ditties--observations really, of a rainforest. Or at least, that was all that was in it--ditties--until my blood sugar was freakishly low and I somehow located a pen and started tearing at the pages with it. I was terrified, in that moment, of death, without knowing why. I had no idea my blood sugar was low, just knew that God was holding me in his hands at that very moment, pondering whether to keep me on the planet or toss me out, into the abyss of Hades.

And I was terrified. My mind flashed, somehow, and without anything more than incredibly tangential reason, to Cat Stevens, and how he had decided to dedicate his life to god and become a muslim after he had almost died swimming in the atlantic ocean and got caught up underneath a rip tide. So I wrote a prayer, a plea, and a mantra on the quadrille lined pages of my yellow journal, demanding that god forgive me for all that I had done and to allow me to live a little longer.

Delirium had made me a sniveling religious fiend.

I eventually escaped such a fate when I--fortunately--started chewing on sugar tablets sitting next to my bed. I then made my way to a late breakfast, where my advisor berated me for my tardiness and my rather dulled affect. Oh, but if only I had known then what I know now: "I mean no disrespect, but unlike the rest of you, I just spent the last hour in delirium."

Anyway, the second delirious state happened literally an hour ago.

Having awoken five minutes before class started, I had no time to locate my test kit. But I had a headache, and I had gone to bed with a bowl of popcorn recently consumed, so I assumed that my blood sugar was the cause of the headache and thus I needed insulin. Well, within the next thirty minutes I realized that my blood sugar had probably been fine when I started feeling the chest tightening spasms of hypoglycemia. No matter! I had fruit snacks!

And thinking that I had avoided the ills of hypoglycemia, I settled in to taking notes on a lecture about epilepsy.

And here's where it gets interesting: Somewhere--about an hour and a half into lecture--I stopped being able to understand the slides I was reading on my computer. And then, shortly after that--the lecturer stopped making sense. I wanted to raise my hand at several points along the way--I wanted to clarify what he was saying because I was sure he was saying it wrong, but I didn't. Instead I just sat in awe that everyone else seemed to understand what was going on.

And then the madness truly sat in.

We switched to a new professor for a new class, and my head wouldn't stay straight on my shoulders, my neck wobbling side to side. I became obsessed with the fear that the professor would notice me in what would have looked like a sleeping position and that I'd be kicked out of class--or that I'd automatically get a 0% on my next exam. So I snapped my head up and sat up straight as possible. But it was useless, because inevitably my eyes would close and my head would fall forward and I'd look like I was sleeping again.

I tried to focus on my computer, on my notes, but they no longer made sense. I tried to play a little game on google+, Triple Town, to see if that would wake me up, but I was exhausted and I quickly closed the tab on my browser and was unable to pull up anything again. I was exhausted; not tired, just thoroughly incapable of movement or thought.

I soon became incredibly confused and scared. Didn't anyone else feel this way? Why did nothing make sense anymore. I could hear the words my professor was saying, but they didn't make any sense. I became preoccupied with a feeling that I didn't exist, or that if I did, I existed on a plane unlike the one everyone else seemed to belong to. Kind of like I was the only one who realized that this world was simply a matrix, and that I needed to find my way back to reality. But how to get there?

I needed help, but from whom?

I decided that I needed to go to either the counseling/health center at school--a five minute walk away from my current location--or to my mother, who I was beginning to doubt was actually my mom at all.

But at both locations I would have done the same thing: fallen on the ground and started yelling that this wasn't real and that someone needed to find out what was wrong with me. "Run all the tests!" I imagined yelling to anyone who would listen. There was something terribly wrong with me, I just didn't know what--but I needed to know. 

My daydreams kept escalating in preposterousness until I imagined grabbing a knife and stabbing myself in the heart to regain entry to the "real" world that was hanging just outside my grasp. The thought of stabbing myself terrified me. And that simple feeling--intense fear--called my logic to attention.

What if this was just hypoglycemia? So I formed a plan while my professor kept garbling through his lecture on... what was it? ... anticonvulsants?

Step 1: Get Food
Step 2: Wait to Feel Better
Step 3: Feel Better? If no, go to Mother
Step 4: Feel Better? If no, stab self in heart

Fortunately, after eating a snickers bar, a twix bar, one reese's peanut butter cup, and a can of coca-cola, the delirium surrounding me started to fizzle away. I was capable of speaking, although my tone and volume were way off when I asked one of my friends sitting in the row in front of me, nearly incoherently, where today's pathology quiz was going to be administered. But I was conscious, and the fear that I didn't exist or that I existed in a parallel universe or a mirror reality, quickly became nonsensical and strange. Shortly thereafter, I was conscious enough to begin writing this, an assessment of my mental status as it descended once again into a state I wouldn't recommend for anyone. And that's delirium for you.




(a little bit more for the intrepid reader):

so delirium can be caused by anything that wholly affects the brain. usually when i have just bad hypoglycemia (so not life threatening but unpleasant), i act like i have a frontal lobe lesion: poor planning, flat affect, avolition, etc. however, the two times i've become "delirious" from hypoglycemia, it's possible that I was under the spell of global cerebral ischemia (so involving the entire brain). And while it appears that to get global cerebral ischemia from hypoglycemia, low blood sugars have to occur chronically (i.e., insulinomas), I fully believe that an hour of really low blood glucose could knock a person delirious.

(the end)

Cheap Medicine

"Don't be the ones who order labs because by the time you practice we won't be able to afford the labs."

-Psychiatrist Professor

Empowered

So thanks to my involvement in Step Up (a tutoring/mentoring program at NCCHS) and AMWA, I feel like I can do anything. Or at least, I can try to do anything. I have the resources and the know how. I feel as though I can affect change in my surroundings--and what could make anyone feel more powerful? Regardless:

The American Medical Women’s Association (AMWA) at my school is really awesome. I’m not just saying that because I’m on the board, but that fact helps a lot.

Regardless, last year was the first time we put together an event called the “High Heel-Athon” which was designed to raise money for a domestic abuse shelter in Chicago. It was a good event in that we raised a lot of money—over $500. It was not good in the turnout. We got about 14 people, including board members, which was depressing, at least to me, a lowly M1 who had yet to realize that medical students are flooded with apathy.

So this year, the president, the ambitious and awe-inspiring Alice Lee , and I, decided to tone it back a little bit, and have a High Heel Gala instead. We were going to get a speaker to give a speech, pertaining to domestic violence and what we as medical students should know, and how we should aspire to deal with the situation when we became practicing physicians. We wanted to not only raise awareness, but we also wanted to help our peers become better physicians.

Unfortunately, we couldn’t find a speaker, so instead my mother (a professor at the school) suggested we give the presentation ourselves. So we did! And not only was it really nerve-wracking, it turned out totally amazing. Alice Lee and I are both creative types, so the presentation looked pretty. Alice Lee talked loudly and authoritatively, and I rambled somewhat less than usual (I suck at preparing speeches; “I’ll do it live!”)

Even better, more than twenty people, not including board members, showed up and many of them said they enjoyed the presentation. So below, for your benefit dear reader, I’ve posted some of the more informative slides:

Compliance & Threats

Currently I am in Clinical Neuroscience. We are being lectured to about sleep disorders, specifically sleep apnea. The guest lecturer appears to be in the range of 40-60 years of age.

Concerning sleep apnea, there is a fairly successful treatment: continuous positive airway therapy (CPAP). Unfortunately, compliance with CPAP is pretty low. Only 46% of patients use the therapy, and of these persons, only 70% use it on a regular basis.

The lecturer urged us to tell our patients: "You're going to die in the most horrific way imaginable then list all the complications of uncontrolled sleep apnea."

This was one of my major complaints for my previous endocrinologist: vague threats. I can understand why doctors would want to do this--it is really frustrating when you're trying to help someone when they're not trying to help themselves. But I wonder if there isn't a better way to tell someone that they're killing themselves. Would this involve asking them about their life goals and how non-compliance will negatively affect these goals? I think it does.

Regardless,

I suppose doctors are among the few people that can tell you--in disturbing and exact details--how you're going to die without you freaking out and calling the cops.

Manic Depression

[Warning, explanation: this is the most personal blog post I've written so far, so if being close to people makes you uncomfortable, you can skip this. But it's medically related, technically]:

Psychiatry Class. 9 AM. Dr. S is giving an cursory lecture on various mental conditions. He gets to mania. He starts listing off characteristics. An entire row of students in my lecture hall, turn around to stare at me.

Am I manic? Perchance.

Like many mental conditions, you have to have a certain number of listed signs/symptoms in the DSM to be able to classify yourself as anything. But I do have some symptoms of mania:

Debt

There are 65,000 medical students in America. That's 0.02% of the population. They graduate, on average, $149,000 in debt. That's a total of 9.1 billion dollars of debt. That's 0.05% of our countries national debt.

9.1 billion dollars, however, would be covered by the income of the two largest health insurance companies in America.

Single payer system?

Yea. Maybe we should think about that. Or anything, really. This system is not sustainable and pissing off future doctors isn't really something this country should be doing.

vaccinations! get some

http://www.ct.gov/dph/lib/dph/VPD_US_statistics_2010.pdf
http://www.behance.net/leon_farrant/frame/2878481

We're learning about vaccines in microbiology. It really weirds me out that we have a chickenpox (varicella) vaccine now, because I didn't get one when I was a kid (it was created in 1995, by which time I had already had it). Also amusing: chickenpox affected over four million kids a year? That's crazy. 

Obscure Medical Condition (1/2)

Several weeks ago I woke up in the middle of the night. I wake up in the middle of the night a lot--I've never been a good sleeper. Usually when I wake up in the middle of the night, I resign myself to the fact that I'll either be awake for the next two hours or I'll take another benadryl and I'll be asleep within the next two hours. But this night I notice something unusual when I swing my feet over the side of my bed to get some benadryl: I can't feel my right foot.

At first I assume this is just a thing, like how your appendages--arms, feet, hands--lose sensation in a variety of situations. But once I've taken my benadryl and am sitting on the side of my bed, I begin rubbing my foot and I still can't feel my middle toe. After about two minutes I begin freaking out, or as much as one can freak out in the middle of the night: rocking back and forth, mumbling prayer-esque incantations, crying.

The symptom, the chief complaint if you will, is Peripheral Neuropathy.

I pull up a differential diagnosis in my mind. Top of the list, do-not-miss: Diabetic Neuropathy. This is terrifying because I am twenty-three years old. Statistically, I have a lot more life to live. I don't want to live it without my legs. But there are more diagnoses--less depressing than diabetic neuropathy, but still depressing.

Chronic Alcohol Abuse. I drink a lot. I assumed I was safely staying within my Federally Mandated limit of two drinks a night. But maybe I was drinking much, much more than that. Although alcohol abuse and pancreatic cancer aren't directly tied to one another, I am still pretty terrified that I will get cancer, and over drinking to the point of developing peripheral neuropathy seems like over drinking enough to give me some type of cancer. Even worse: Alcoholics can develop Korsakoff-Wernicke's syndrome. Now Wernicke's aphasia would be awesome! But the Korsakoff part of Korsakoff-Wernicke's leads to being delusional and "confabulation." I don't need to be any more delusional than I already am.

[Question: Why does chronic alcohol abuse lead to peripheral neuropathy? Answer: A) Alcohol dehydrogenase requires oxidizing agents and can quickly use up important molecules like thiamine (Vitamin B1) or B) Drinking distracts your liver from doing other important things, so that it can't send out as much cycling lipids as it should. Neuron helper cells can't keep producing myelin, and you lose nerve conductance. At least I think this is how it works... If you have a better way of explaining it, please share!]

Malnutrition. I had been on a diet the entire summer. It was great: lost 15 pounds, and now my BMI is 22--super normal. However, there were days when I went "overboard." I tell myself it takes a lot of willpower to only eat 565 calories a day, but it's still probably not a good idea. Being able to lose a pound in a day feels awesome! But really, you should be losing that much in a week, if not even over longer time periods. I tried to eat well, the little I did eat was healthy, but it's possible my body needed more and began shirking its biosynthesis responsibilities, resulting in me losing sensation in one of my feet.

So what do you think I have?

Patient History

Patient is a reliable, 23-year-old diabetic (DM type 1).

CC: Patient's chief complaint is an inability to feel her feet.

Past Medical History

Patient has been diagnosed with:

sickle cell trait (congenital)

exercised-induced asthma (age 8)

seasonal allergies (age 8)

Diabetes Mellitus Type 1 (age 13)

anemia (age 15)

hypertension (age 18)

hyperlipidemia (age 18)

depression (age 19)

Medication

Patient is currently on:

Humalog (short acting insulin)

Lantus (long acting insulin)

Nasonex (seasonal allergies/allergic rhinitis)

Fexofenadine (seasonal allergies)

Atorvastatin (hyperlipidemia)

Vitamin B12 (2000 mcg/day)

Social History

Patient denies recreational drug use. Patient admits to smoking cigarettes, about 8/year and having 1-3 drinks/day, occasionally drinking more (6-8 drinks/night) on weekends. 

Patient exercises about 30 minutes everyday.

Family History

Patient's father is alive, has hypertension that has been controlled by diet, and glaucoma.

Patient's mother is alive, has dyslipidemia, and had breast cancer in 2007. Currently in remission.

Both patient's sisters are alive and healthy.

So what do you think I have?

This is what makes studying bearable:

Our second exam of the year is this monday. I have now been in the library, at the same wooden cubicle, for over five hours. My back hurts, I haven't eaten anything in eight hours, my carpal tunnel is flaring up, and I am literally itchy all over (study-induced pruritus, probably).

That being said, the soon-to-be-tested-upon material is, by my estimates, twice as cool as anything we learned last year and an infinite amount of times more useful because last year we didn't learn anything clinical. Last year was just cram, cram, memorize these dumb facts about obscure biochemical pathways.

How helpful has this year already been for me? I'll tell you:

No Duh Aristotle

Sometimes bioethics can be really dumb, and yet so disturbingly profound.

No, that last half is profoundly sarcastic.

Here is a fun quote from our Bioethics text:

"Common to all theories of justice is a minimal requirement traditionally attributed to Aristotle: Equals must be treated equally, and unequals must be treated unequally."

NO. WAY.
I think my brain just exploded from the complexity of that statement.


But to be serious for perhaps a paragraph, I really enjoy bioethics. I miss writing things out. Also, it's fun to posit ridiculous arguments. However, I don't know if I'll ever write anything more ridiculous than the following sentence I wrote for a discussion on vaccinations:

"I think we can safely assume that this family is inherently evil."
So get your kids vaccinated! 

The Rhythm Method

So fun fact: the rhythm method is an actual form of birth control. I was shocked, too, mostly because it seems like it's the preferred birth control method of Republican Presidential Candidates. 

The basic premise is that you can't get pregnant on certain days of your menstrual cycle. Okay, several problems:

1. Gross. You mean to tell me that married couples will talk about menstrual cycles in the context of not wanting to get pregnant? I assumed that men only talked about menstrual cycles when they were trying to get their wife/girlfriend pregnant. I guess not. Once again, gross.

2. How do people even understand the menstrual cycle anyway? It's not impossible, but it's one of the more complicated segments of human reproduction, as evidenced by the fact that our physio professor has now been talking about the cyclic nature of hormones and metabolism for the last twenty minutes… and we're not even close to done yet. Furthermore, yea, menstrual cycles are pretty constant, but they can change. So using the rhythm method could still get you knocked up if you're planning on avoiding sex five days before ovulating. SURPRISE! You started ovulating early. Here's a baby.

Basically, it's complicated, so why would you tell people that they need to figure it out for themselves instead of just giving them birth control?

3. And finally... What the hell?! The rhythm method?! That is just so ripe for making fun of! It feels so much a euphemism, and not something that is actually scientific, that I can't take discussion of it seriously. Public health. Ridiculous.

Additional fun fact: we have started the reproduction portion of our basic science courses. I am scared.