Circular Reform II

The meat.
The Poobah feeds us what he thinks good curricular reform looks like. We need to get away from spoon-feeding lecture material and move toward problem based learning. We neeed to encourage life-long learning. We need to promote horizontal and vertical integration, i.e. I need to talk to more 4th years. We need to get away from the 2+2 formula of medical education where there are two years of preclinical class-work and two years of clinical apprenticeship in the hospital. We should replace it with a 2x2 formula that promotes more integration between the preclinical and clinical worlds. I wonder if he's aware that, on a stricly mathematical level, 2x2 = 2+2? Obviously, this is deeper than math. Of course, I have no idea how 2x2 might work, and Poobah gives no pointers.

Poobah also encourages our initiative to promote good teaching and our huge push for professionalism. Little does he know that our professionalism teaching actually includes (see Hubris). Finally, he says that we shouldn't be seduced by false outcomes, things like standardized exam (board) scores, student satisfaction, and residency results (the Match). After all, we're amazing students, so we should do well on the boards regardless.

He talks about the need for humanism and the goodness of having a standardized patient interview as part of the 2nd step of the boards. He talks about the possibility of changing pre-medical requirements to start out with better trained students, or other larger reforms. In response to questions, he complained about the loss of low-income students who don't understand that they'll be able to pay their way out of the enormouse debt burden that medical school entails, and speculates unproductively about how medical schools can decrease their costs.

Ahem.

1. There's no data. I complained about this on the way out, and another student said, "There is data, he just didn't show it to us. If he had, it would have taken six hours." Maybe, but without the data, the hour speech is a waste of time. As Poobah said, one of the major obstacles to curriculum reform is student opposition.

2. I have very little to say to a fourth year, thank you very much. I mean, we can talk, but when we do I don't learn things that I need to know. Unlike undergraduate, there's not stuff that you need to start right now or you'll be screwed, because all that stuff is built into the curriculum.

3. 2+2 is not on the table. Sure, the inspiration for this system (The Flexner Report) is almost 100, but that doesn't automatically make it wrong. More significantly, the dean's office told the MSTPs that this is unlikely to change. Since we do 2+4+2, a major disruption of the 2+2 system will affect us deeply. This isn't to say that they would never do anything to inconvenience us, but they gave no details on what the reform would be, other than to say 2+2 was unlikely to change, which makes me feel more confident that it will be protected.

4. The reason DMS couldn't tell us what the reforms would be is that they pitched them as being student originated and student driven, so I resent the possible implication of this meeting that reform will be centrally designed and executed.

5. Problem based learning is not a panacea. For the non-medical types, PBL is a system where, rather than sitting in lecture, students are put in small groups and assigned problems to deal with. In medicine, these normally take the form of cases. The varied parts of the case serve as teachable moments, e.g. we have a patient with poor circulation and use it as an excuse to talk about hemoglobin. At the same time, we can talk about the physiology of circulation, how to interview this patient, what parts of the history are significant, how to deal with this patient's access to care etc. etc.

This sounds great, right? Kind of. This environment isn't the best environment for everyone. Some people love lecture (I go back and forth). If you don't learn from lecture, you just don't show up. If you don't learn from small group, they still take attendance, so you get to suffer through however many hours of groupthink, then go home and try to learn it your way. Regardless, some things are just better lectured. The tie-ins can be somewhat contrived. Each small group has to be led by someone, who will either be a professor (expensive) or a TA (useless). There's also no way to standardize what a small group will cover. Do you want to be treated by someone whose group shortchanged the hemoglobin, or the history taking? What happens when they have a patient that isn't a case? There are thousands of pathogens and drugs that 2nd years have to know cold - how is that case-able? Switching to case-based learning would also require Dupont to build us a huge new expensive building to accomodate the numerous small groups, making the transition that much more expensive.

Every generation has its own educational fads. Whole language. Integrated Math. International Baccalaureate. Self Esteem (ugggh). How do we know that PBL is a real advance and not a random gyration or cul-de-sac of edu-bureaucra-somethingorother?

6. My last question is not solely rhetorical. How do assess whether a pedagogy works? It's not trivial. One way is to look at internal grades. Early in Harvard's New Pathway program, for instance, rather than teaching students the names, origins, insertions, and actions of the muscles, they just taught them that muscles have names, origins, insertions, and actions. These students were quite noticeable in their 3rd and 4th years as they were the ones that had no f'ing idea what they were doing. We don't really have internal grades, so this won't work too well.

Since medical school involves a lot of material, one simple and obvious way to test multiple pedagogies is a standardised test, like the US Medical Lisencing Exam, and see whether a pedagogy improves scores. But Poobah said that board scores don't matter because we're such stellar students that we'd do well anyway. No. Look at Baylor. They teach to the boards to an outrageous degree, and their board scores are significantly higher than say, ours, since we basically ignore said boards. Thus, pedagogy can have an impact on board scores. Second, it's ridiculous for a person that is (somewhat) involved in running the USMLE to say that it doesn't measure anything. Emphasize touchy-feely all you like, but there is a body of knowledge that doctors MUST posses. The degree to which a school imparts that information is relevant, even if it is not the whole story.


MBA programs are ranked by how much money their graduates make after 3 years. The analogous system for medical schools would see where people go for their residency. This seems more reasonable than board scores - the application process involves interviews, recommendation letters and descriptions of our performance in clinical clerkships. If I've learned nothing, continued my unprofessionality, and turned into a peronality-free robot, they'll notice. There are problems with this, obviously. It's less quantifiable than boards, unless you want to assign points based on how prestigious the specialty and location of the residency are, which would itself be arbitrary. Since residency is a matter of matching, in which students rank their preferences, you could see what percentage of students get their first choice, but what if I rank a place first because I know they're the only place that will take me? Finally, part of the reason I'll get into a specific residency is because I went to Dupont. The system is sticky - difficult to change. Still, looking at the change in our performance, relative to ourselves, provides some quick feedback.

One could argue that the true definition for success lies in the future, some 10 years hence, when they see what kind of doctors we are. This is horribly non-quantifiable. How are they going to assess our competence then if they admit it's impossible to measure competence now? Is it going to be outcomes, in that our school is better if we place more professors? That ignores the fact that most people don't want to be professors. Should we do take-home pay? How uncivilized. It does however, have the advantage of being a realistic assessment of your value to society.

Once you eliminate ways to compare programs, the relative value of programs is dependent entirely upon reputation. For instance, we have a reputation as a "Top 10 medical school," when, in fact, we're not. Not even close. But the strength of the Dupont brand is such that we seem that way. Or something. The whole 'not top 10' is based on US News's rankings (http://www.usnews.com/usnews/edu/grad/rankings/med/brief/mdrrank_brief.php) which, in the absence of better data, will be the way med schools are ranked (which should be incentive for developing alternate rankings). Let's look at the rankings and methodologies (http://www.usnews.com/usnews/edu/grad/rankings/about/06med_meth_brief.php): Reputation. Reputation. (This counts for 40% of the score, btw). NIH grants total, and per researcher. How this affects the quality of my MD-only colleagues education, I couldn't say. Note that the total is more heavily weighted than the per-researcher, thus encouraging schools to add mediocre scientists.

The next part is hillarious. Acceptance rate - what this has to do with quality, again, is unclear. Plus it encourages schools to drum up applications. Also, is this based on primary applications, or secondaries? A primary application costs $30 and all you have to do is check another box on the common app. To do a secondary, you actually want to go to the school. MCAT - yes, let's replace using board scores for a test that wonders whether you remember your cyclohexane chair conformations (http://www.cem.msu.edu/~reusch/VirtualText/sterism2.htm) from OChem. Undergraduate GPA - . Enourages schools to accept people that avoided PChem and/or classes that they thought would prove difficult - these are precisely the sort you want for your physician, no?

Faculty/student ratio is interesting. Note that's faculty members per student. We're not in undergrad anymore, dorothy. And while I would appreciate getting picked apart by 9.5 professors if I went to Harvard, I'm not sure I would notice if it was only the 4.5 that would be after me at Hopkins. Again, this encourages schools to hire more crappier professors, or relabel reserach assistants and other non-helpful people as 'teaching faculty.' Next to these metrics, board scores and %1st pick for residency seem downright brillant.


Satisfaction
The third criterion rejected by Poobah is student satisfaction. I've heard the argument before: I have no basis for comparison. I don't know whether my level of knowledge is actually good or competitive, only how it measures in the eyes of the very people I'm rating. Just because I had a good time in class doesn't mean I got anything out of it. But, as Poobah says, we're good students. We went to top schools. We take out knowledge and try to think about problems. We have a basis for comparison - it's called undergraduate. I've been taught physiology before, and I know when they're doing a bad job. We're here to learn, and we can tell the difference between when the professor is imparting useful information, imparting details about their research, and goofing off, and we rate them appropriately.

Circular Reform I

Obviously, Dupont needs to change the way it educates its students. I'm not talking about obvious, low risk, and brilliant moves, like rehiring Dr. X. That's far too petty. Rather, DuPont needs to completely rejigger its curriculum, and in doing so leapfrog ahead of other medical schools and have:

THE CURRICULUM OF THE 21ST CENTURY

We got a speech on this matter from one of the GRAND POOBAHs of the medical establishment.^1 It occured at noon, after a morning's worth of classes. Lunch, paradoxically, was not served. One of the constants of medical school is that when they want you to do something, there's free food. Nonetheless, the entire 250-seat auditorium was filled, with numerous upperclassmen sitting on the stairs. First, the dean got up and introduced the poobah. They went through this guy's whole pedigree (Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard, Harvard)^2 Note that he's ~60 years old. Is that philosophy conversation he had with Chas during the Eisenhower administration really this important? Fortunately, they also went over all the crap he's done since then.

About midway through the resume, I was struck by a thought, "How cool is it that we live in the age of empiricism, where all the resume in the world does no good if the data is against you?" And I resolved that I wouldn't believe a thing unless I got the data. I have a grad class where people will refuse to give any credence to a paper because there's a shadow in one of the gels. Should we require the same standard before we muck up a generation of Dupont grads?

1 Saying who would be too much, but this was one of the top 20 people in medical education. Think deans of medical education, AAMC apparatchiks, medical education 'experts,' psychology types etc.
2 That's preschool, grade school, high school, undergraduate, post-baccalaureate research, MD, PhD, residency, fellowship, professoriate, chairmanship, initiative directorship, and deanship. As I wasn't taking notes, my rendition may be slightly innnacurate.

Has it been this long

And nothing has really gone on? The honest answer is yes. I am of the opinion that in order to write, you must have something you want to say. This is part of the reason I got out of writing as a field - I don't think that my ideas, in and of themselves, are of much originality or value. In my case, I've got nothing to push against.

The pressure of summer is basically gone. I no longer study every night. If I did, I would be so far on top of everything it would be ridiculous.* I try to amuse myself with pathology conferences or radiology visits, but scheduling for them is inconvenient given the amount of class I have. It's becoming obvious that I can improve my day immesurably by simply skipping the first lecture of any given day.

Why is the pressure of summer basically gone? It's simple. Anatomy and histology are two large concept areas where I had no previous knowledge. Zero. We receieved bone sets our first day, and I couldn't identify squat. Histology didn't start out as pinkish bluish ovals, it started out as 'can't focus on the image 'cause I don't know how to use a microscope.' Contrast that with physiology. Our med physio class is 100 'hours,' long, whereas my junior level physiology was 75 'hours' (Or 90 or 105, depending on how you want to count the lab) and taught on the same, if not a higher technical basis. The prof at Norbert, for instance, did us the courtesy of assuming we understood metastable kinetic states, and how they related to sodium channel opening (in a purely qualitative way, but still informative). For grad courses, Cell Biology and Proteins (my biochem course) are concepts I've heard before, just slightly embelished. Cell Death can surprise, like when we learned about mitochondrial calcium absorption, but it's more of an integrative class that stitches together what we already know than one which introduces big volumes of new data.

One might wonder why Physio is such a waste of time. Is it the variety of incoming preparations? My physio experience is certainly not representative, so this may have something to do with it. Is it the professors insistence on not telling us things, even in outline, that other people will teach us, and recapitulating how patch-clamp works 50 times? I'll give an example: Two weeks ago, we were lectured on the various membrane proteins involved in Long-QT syndrome, and then tested on what they were. I surveyed about 10 people in my class, including a few MSTPs, and no-one knew what QT referred to, or why it would be bad for it to be long.** It takes me about 5 minutes to explain this in simple terms any beginning med student can understand. Why don't the profs do this? Finally, the first years have a lot of other stuff to do. Physio has a rep for being an easy class where you just study the old tests, which is basically true. Our anatomy-heavy curriculum doesn't give it sufficient time to elaborate to the point where it would be revolutionary for me.

I guess I do have some stuff to say, though admittedly it is just dumb griping. We did get a lecture from a medical bigshot on how to reform our curriculum, so that will be a lot of fun if I ever do write about it.



* Why would being on top of everything be ridiculous? First, it would make classtime a complete waste. Second, I need to recouperate and save my powder for when it really counts. Third, I'm a gist kind of learner, sloppy intellect with a long memory for concepts. Hard work would just clean up the details, which would ultimately blur anyway.

** QT refers to a measurement done on EKG. It works like this, on EKG, each heartbeat has 3 big waves. The P wave is the electrical signal from the atria contracting and priming the heart. The QRS complex is 3 waves clustered together that represent the ventricles squeezing blood out into circulation. The T wave represents the ventricles relaxing. The QT interval is the amount of time (x-axis) between the beginning of the QRS complex and the end of the T wave, that is, how long the heart is contracted for. If this is too long, it means that the heart will still be contracting after all the blood has been squeezed out. It would be far more efficient to relax and let in the next round of blood. Failure to do so means that less blood gets pumped. This is 'bad.'

Powerful Medicines I

At the White Coat Ceremony the Gold Foundation for Humanism in Medicine gave us two books. One of them is On Doctoring, a collection of stories, poems, and essays about medicine. It's unobjectionable. The other is Powerful Medicines: The Benefits, Risks, and Costs of Prescription Drugs. 70% of primary care medical visits result in a prescription, and thus it's important that we get it right.^1 The conceit that this book is essential or useful needs to be examined more thoroughly.

This is going to be a fairly lazy book report. The first thing I'm going to do is take a poke at the author. Actually, the only thing I have on him is that he's been at Harvard since 1969 (p 231), and he's still only an associate professor. This is probably because he's too busy running the Pharmacoblahblahblah divisions at The Brig so it probably doesn't signify.^2

I would, however, like to take aim at Bernard Lown, M.D., winner of the Nobel Peace Prize and possibly one of the biggest malpracticers in medical history. A bit of background: Your heart has a normal rhythmic beat. In some people, a heart attack or other some such causes the heart to become very a-rhythmic. These people are at high risk of keeling over with no warning, a phenomenon known as "Sudden Cardiac Death." As it turns out, if you study most people, we have a few arrhythmic beats per day. Lown (and many others) figured that if a lot of arrhythmic beats are bad, a few are still a problem. Lown proposed that treating mild arrhythmia would prevent Sudden Cardiac Deaths. With no evidence other than Lown's say-so, thousands of physicians began prescribing the treatment for mild arrhythmias. When a clinical trial was finally conducted, they found out that the treatment caused sudden cardiac deaths, rather than preventing them.^3,4 The whole story appears in Deadly Medicine: Why Tens of Thousands of Heart Patients Died in America's Worst Drug Disaster. Deadly Medicine calculates that around 50,000 excess deaths occurred because of Lown's conjecture. However, a 1997 paper argues that no extra deaths appear in the epidemiology as a result of doctors trying to suppress mild arrhythmias.^5 Regardless, Lown hectoring about the need for evidence-based medicine is pretty rich.^6 It's also interesting to note that Lown is a (the?) senior physician at The Brig, and thus in some way Avorn's boss.


Next post: The problems with the content (as opposed to the dust jacket).


1a. What this means: You have a problem that you decide needs medical attention. You visit your family doctor, pediatrician, internist, woman doctor. There is a 70% chance that this individual will prescribe you something. This doesn't include getting referred to the dermatologist and the derm. giving you something.

b. Factoid from Clinical Skills - 75% of diagnosis are made on the basis of history alone, and 90% are made from a combination of history and physical exam. History is everything the patient says. Physical exam is where you take weight, height, blood pressure, get your knee tapped etc. etc. This seems to imply that most prescriptions are given on the basis of minimal information. You may argue that for someone with high-blood pressure, not many tests are necessary besides taking their blood pressure during the physical exam. I would counter that a lot of people are getting prescriptions for antibiotics without getting a culture taken to see if they actually have a bacterial infection. Over-prescription of antibiotics leads to antibiotic resistance, so this is not an academic problem.

2. The Brig (and indeed any of the Harvard Hospitals) is considered one of the most desireable places to go for residency.

3. Everyone was so convinced that arrhythmia suppression worked that they wouldn't enroll their patients in a trial and risk them getting a placebo. At a conference where the primary investigator was describing the results, one of the attendees stood up and said, "You are immoral!" (this is from Deadly Medicine).

4. Pratt CM, Moye LA. The Cardiac Arrhythmia Suppression Trial: background, interim results and implications. Am J Cardiol. 1990 Jan 16;65(4):20B-29B. PubMed

5. Anderson JL, Pratt CM, Waldo AL, Karagounis LA. Impact of the Food and Drug Administration approval of flecainide and encainide on coronary artery disease mortality: putting "Deadly Medicine" to the test. Am J Cardiol. 1997 Jan 1;79(1):43-7. PubMed

I know nothing of epidemiology, but their method seems rather unsophisticated, especially given what Avorn says about epidemiological research.

6. Lown's quote is actually about "the corrosive effects of commerical influence... Thus, to poke fun at him for this, I have to go into how his arrhythmia suppression hypothesis required the development of new, more easily tolerated, drugs to give to patients that didn't feel ill. It was because of this theoretical market that the drug companies chose to develop the new drugs. Lown's hypothesis provided the rationale under which they were able to sell their drugs to more patients, including those outside the category for which the drugs were initially improved. Thus, Lown arguing about the need for evidence-based medicine is rich, as is Lown arguing about the corrosive effects of commercial influence.

Hubris

We had a professionalism day. This is the day where they tell us that professionalism is difficult to define, invite us to dialogue about professionalism, lecture us for five hours about professionalism, then tell us that we're ready to be professionals.

Anyway, Dean Hillary* is asking us about the merits provided by professionalism. Then she asks, "These merits may bring on a tragic flaw... does anyone have any idea what that is?"

Hubris. It's always hubris. Life as a Greek tragedy. I raise my hand.


*Not their real name.

Clinical Skills: The science of communication

This class, the whole "you're a doctor now" class is pretty boring. Our first lecture was on how important communication is. Then we had a lecture on how to talk to people, "Ask open ended questions... Give non-verbal reinforcement (mmm-hmmm, head nodding etc.)... Summarize what your patient says." This is mostly good for a few bad jokes.

I: This summarizing thing is so stupid. Won't people just get annoyed?
C: So what you're saying is that summarizing is annoying.

S: So how old are you?
I: I'm 25
S: How long has this been going on for?
I: Couple months.

I: Why did you come in today?
S: My knee hurts.
I: No. NO NO NO NO NO! You're getting it all wrong. It's supposed to be your knee.

Anyway, research indicates that first year medical students take a better history than upperclassmen, who take a better history than residents, and so on up the medical ladder. The solution ot improving patient-doctor communication? ABOLISH MEDICAL SCHOOL.

The whole communciation thing is unsurprising to me because even in normal conversation I try to do the same things, have ever since I un-gave-up on the non-supernerds. I've been accused of trying to make stilted and controlled something that should come naturally. On the other hand, it's transformed a lot of anemic conversations, so I'm willing to work with the science of communication. In principle.

An excess of normality

Something strange happened this week - it was dull. Dupont over the summer was like nothing I've done previously. Conversely, this week has felt like part of another year at Norbert. Lots of sitting in lecture and paper reading. I even had to write a critique adjudicating between two different viewpoints of a single phenomenon which were articulated in readings - just like an English class. The material was also much more comforting. I have much more experience with ion channels and lipid bilayers than I do with cranial nerves and brachial plexi. There two exceptions thus far - autopsy conference and clinical skills, which I'll post on... maybe.

Orientated

Orientation is finally finished. All programmed time, all day, every day. More tiring than actually going to class, I think.

Decompression IV

4. Finally, and probably most important. I spent a lot of time this summer trying to fit in with my class. Ultimately, I think I wore myself out and didn't leave a good taste in my classmates mouths. Hopefully over the winter I'll be able to make actual friends at Dupont, and if I can't, I'll just have to range farther, because spending time pretending that I can be whoever people want me to be is simply a bad idea.

We interrupt this whiny series...

To present an item from The Guardian's series "Bad Science."

One of the things that happens when you're a science graduate is that people always ask about these things - is red wine good? Why? What about white? How about chocolate? Of course, I haven't read the paper, so the honest answer is, "I don't know."* This is an extremely difficult answer to give when you've just spent the last half hour hearing about baseball stats, or that one time that this one guy got, like, so trashed, and you know that if you don't take the bait, it's right back into the box scores, or...

My urge is to bash anything too radical, mostly because it's unlikely to have been reported correctly, or to be a poor trial design (one that's small or doesn't consider alternate hypothesis that are more reasonable, e.g. children with MS are unlikely to have younger siblings because the parents are too busy dealing with the sick child to produce or care for another child). Of course, my cavalier treatment does cause the appearance that scientists are high priests flinging rhetorical missiles at one another, based on totally arbitrariness etc. etc.

One of my teachers at Norbert U, a lab instructor, told me not to get a PhD. She said there were too many of them and that I should instead take up science writing. I guess that means that if my work is incorrectly portrayed, I have only myself to blame.

*In fact, I barely read the abstracts linked to above. They're simply some of the first abstracts that came up on PubMed

I originally clicked over to the Bad Science post because of a post on: Instapundit

Decompression III

3. It doesn't have to be that way. I don't have to be a single PI, solely responsible for myself. I can find collaborators and set up something permanent. Being the sole professor interested in a single area in a university can give you some crazy ideas, but a good partner can help you balance them out. This is something my advisor has done, and it works well for her. Similarly, I can do something other than research. I can go work for the FDA, or a tech company, or even just teach.

Decompression II

2. Success has many definitions. My classmate S____y says that MSTPs tend to be unsuccessful. What does he mean by this? Very few people are amazing physicians and amazing scientists simultaneously. "We all think we can beat the odds." I finally realized that I don't really plan on playing those odds. On my way back from DMS, I swung by Norbert University,* my undergraduate, and had lunch with my advisor. She has a single paper in PubMed, which is over 11 years old. She has no graduate students. She does not appear to have received any NIH grants. And yet, she's very successful, at least by my lights. She changed my life. She is an amazing mentor, mother and a courageous human being (for reasons I'd rather keep private). I'll bet you Hannon doesn't come close. She's also one of the co-creators of the research project that inspired me to get into research in the first place, which brings me to my next point...

* After the Norwegian Ridgeback from Harry Potter and the Sorcerer's Stone

Decompression I

You may have noticed that summer has ended. Summer session ended a couple of weeks ago, and thus I haven't had many relevant thoughts. Actualy, I had quite a few.

1. I dislike anatomy. I've always thought that gross anatomy is like Clue. By the time the game begins, the fun part is already over.* I'm much more of a physiology man. But, Dr. X was so charismatic, and I was so wrongfooted and afraid I was going to get tossed that I confused Stockholm Syndrome for true like. On reflection, it is a bunch of really boring memorization whose exact function for most medicine, most of the time isn't really obvious. I have a better memory than most, and my particular specialty is long-term retention (rather than volume). But you know what? Anatomy is falling out of my head faster than... ummm... (un?)fortunately, most of my hackneyed metaphors have fallen out of my head as well. I had incredible difficulty studying for anatomy, and no wonder - I have a lot of trouble doing things I dislike.


* Blatantly stolen from the tagline for Kill Doctor Lucky, a rather neat product from Cheapass Games, "Why do all mystery games start just after all the fun is over?"

Blogging downside

It burns me to the core when I see blogs talking about themselves. However, much as I hate to admit it, the first Google search result for "patientetherised" is this website. I hate the fact that I'm saying it, or even that I noticed. It's like a circle jerk with only one participant. I'm so so sorry. Substantiative posting will resume... eventually. I'm doing something major and medical related on the 18th of September, so hopefully I will have a thought about that before it happens. If not... I would say I'm sorry, but S____y says we Americans apologize to much, so... deal.

My least favorite part

One of the basic organizing principles of medical school is that in the first year they explain how things work (physiology), and in the second year, they explain how things break (pathology). One downside to this is that pathology, and the ensuing treatments, are a lot more interesting than physiology, so as part of our first year, we get introduced to some basic ailments and their treatments, both to illustrate why things are important, and to keep us from getting bored.

From time to time, we look at various types of imaging studies, such as x-rays, CAT scans, MRI, and contrast studies like angiography or barium studies that look at the GI tract. Dr. X will often ask us, "What's wrong?" As in this example:



So, this is a plain film x-ray.* Bone and metal are white, soft tissue is gray, air is black. At first glimpse, there appear to be a lot of bone fragments, little white cirles that don't seem to go with anything. In fact, this is a child. Her bones have not yet finished ossifying, so in some parts they are composed of cartlidge, which doesn't block x-rays the way the calcium in real bone does. The big thick bone coming up form the bottom of the image is the femur (thigh bone) articulating with the three bones of the pelivs. The trick with looking at pediatric images for fractures is that you have to know where it's normal to have breaks in ossification, and where it's not. One easy way is to compare the left versus right sides. A simple analysis is below:


O.K., so the left pubic bone is fractured (x-rays are read as if the patient were facing you). The disrupted pubic symphysis and very slight dislocation of the left femur are results of this. Why is this my least favorite part? The answer is found in the answer to this question - what's the differential diagnosis for a pediatric fractured pubis? This is a complicated way of asking, "What could be the cause?" If you're lucky, thre's a car accident in the near past. If not, the most likely cause is child abuse.




*I don't know who this is, or the age. There are no identifying marks, therefore I consider this sanitized for the purpose of privacy. The image is a picture I took of a plain film, so it is not form any case online.

Survey Part II

The second survey I took recently (see below for Part I) was a course evaluation of the anatomy class whose final is this Friday. Three questions stand out to me:

Please indicate the degree to which you agree or disagree with the following statements from 1 (Strongly Disagree) to 5 (Strongly Agree).*

6. Encouraged critical, independent thinking.
7. Stimulated and facilitated questions and discussions.
8. Motivated independent study in the topic area.

When I got to this point, I said, "Wait, these are course objectives?" It's objectively true that the course didn't encourage these things. It's objectively true that when a controversy came up, our professor would say things like, "We can argue all day about this - Moore says 5 muscles, Clemente says 7, Grant has 4, Grey has 10, Hollinshead says something else entirely. Ultimately, when you think about abducting your arm, it's really only two muscles - supraspinatus and deltoid."** So thinking, discussing, and searching for alternate explanations were never on the plate.

Could this be some kind of crazy form borrowed from the English department because the School of Medicine didn't want to write their own evaluation form? Nope - the forms are different, and the school of medicine one even has our little crest in the corner.

So then, what's going on? I'm not sure, but my next question is - are these things actually course objectives, and should they be? Turning back to Volume I, Page 1 of the syllabus, the course objectives seem to be to:

1. Provide a course of study that will not only be inspiring but efficient and economical.
2. Integrate basic anatomical facts and concepts into a framework of clinical thinking.
3. Be a positive and defining experience - interesting, challenging, and enjoyable.*

No mention of discussion, critical thinking, or independant study. This exonerates the course from false advertising, but the inevitable followup is to wonder whether these course objectives (to the extent that they were fulfilled) form the basis of a viable course. My answer is yes. My impression in this course, as in many science courses, is that the principles of efficiency and economy require us to ignore many controversies, nits, and details, simply because they would distract us from our course of study. Given the choice between covering the material we have, and discussing what makes a "fact" a fact, a 'fact,' a "scientific fact," a 'scientific fact' or what have you, actually talking about something is far preferrable. I can quibble with the best of them, and I don't need more practice.

What about inspiration, acting as a defining experience? Surely I don't go for that crap? Actually, I do. The problem with this blog is that I'm normally only motivated to write when I'm pissed off and partisan, but you can see the chink in my thinking in Survey Part I where I said, "That's why I'm putting up with you people in the first place." There's a big distance between writing an essay about how I want to help people and actually doing it. Somewhere in there is the moment when I stop thinking "How cool is it to be here"" and start thinking "How can I use this to improve the world?" There is the moment when I decide that saving lives is more important than collecting data. There is the moment that I realize that someone's life will be in my hands, the moment it actually is, and moment what I let it slip. One of the outcomes of my interview odessy is that I realized medical training changes you, and I decided that this change is part of my mission in life.

So it's been amazing, nerve-wracking, boring, fascinating, long, grueling, vital, and unique. That's more than enough for any course. Best course I ever had? I'm not sure. Dog Lab was probably the most life changing, Molecular Bio and Physiology are also up there. Let's say Top 7 at least. And despite my last post, just because we don't haggle about the embryological origin of the Sinoatrial Node doesn't mean I'm a soulless technocrat, or that I've lost my ability to dissent. It means I've learned the ability to hold my fire.


* As always edited for brevity and clarity.
** Made up, but representative. The names are names of common anatomy texts. If you really really want to read them, go search for them on Amazon yourself.
P.S. What I can't figure out is why SOM has these objectives on the evaluation sheet if they're not actually objectives for the classes.

Nearing the end

I've finished the content part of anatomy. I've learned the name of most every part of the body, and what connects with what. I know the signs of certain textbook illnesses. I can make sense of studies made with various imaging Devices, such as plain-film x-ray, CT, magnetic resonance, and the images made using various contrast agents.* I have been indoctrinated in simple Procedures used to influence the Sphere of Life. My Genius has been praised. I have sat in on research Symposia, and been introduced to the modern medical Paradigm...

"A mage with this level of Conditioning has been Processed. Substitute a technological focus for each of his Spheres. He is now a Technocrat."**



*Actually, I seem to be surprisingly good radiology - things tend to make sense, and it's the one area where I'm definitely better than my peers (whereas in everything else I'm about average)

**Brucato P, Campbell B, Long S, deMayo T, Taylor S. Guide to the Technocracy. White Wolf, 1999. p90

What this means, to you non-Mage players is that I've been indoctrinated and inducted. I'm one of the brotherhood now, with a diminished tendency to question received wisdom, and the accompanying increase in my perception of self importance and authority.

The Spanish Brandy

I burst into my Program Director's office last week.

I: What does Dr. X drink?
PD: What?
I: Well, our anatomy prof? Dr. X? He's really good. We want to get him a nice bottle of alcohol, and I figured you knew him.* So, what would be an appropriate gift?
PD (Gets out from behind his desk, reaches into his office cupboard, takes out a bottle of Spanish brandy): Give him this.
I (surprised): Is it any good?
PD: Of course.
I (put the bottle in my bag): OK. ... Thanks!
PD: Just don't drink it, OK? And don't tell him I gave it to you.

*The prof in question got this stint by being competant, but also because he crossed paths with our PD, who offered him the job of teaching us.

Surveys I

I took a pair of surveys today. One of them is the AAMC Matriculating student questionaire. Briefly, the American Association of Medical Colleges is the cabal of most every med school in the country (and some Canadians as well, perhaps). AAMC administers the test (MCAT) and the admissions system (AMCAS). They also keep track of what we, the students, think. I filled out a similar survey when I took the MCAT - this lets them compare matriculating students (those going to med school) vs the cohort that takes the test. It's confidential, thank God.

I had to enter my AMCAS ID#, which I probably typed several times a day every day for about six months, but has since completely fled my mind. I had hoped that I might stop being a number at some point...

1. When did you definitely decide that you wanted to study medicine?*

I remember this question from back in the day, because my answer "Dude, I haven't" wasn't one of the options. I guess now it would be "during senior year." Though, my decision of whether to actually practice is still up in the air. My desire to practice is kind of like Stockholm Syndrome. The more time I spend around physicians, the more I want to be one. Conversely, since I started thinking about graduate courses, my desire to practice is receeding.

6. Indicate how important the following factors were in your choice of medicine as a career goal by selecting one of the five options to the right of each factor: (Options are Not at all Important ... Very Important)

a. Profession provides opportunity for research
Very Important

b. Profession provides opportunity to develop expertise in a specialized area
What? I could develop expertise in the specialized area of guessing people's ZIP codes from their addresses... but why? Not at all Important

c. Profession provides opportunity to make a difference in people's lives
Where's the circle for: "That's why I'm putting up with you people in the first place" ?

d. Profession provides opportunity to use manual dexterity skills
I'll let this pass.

e. Physicians can have significant control of their work hours
I dunno AAMC, are you glad you stopped beating your wife?

f. Doctors can find practices that limit their amount of work stress
See e.


7. How important were the following individuals and experiences in your decision to study medicine?

g. Particular book, article, film, television program
No, as a matter of fact, I was not one of those geeks who ran home early from Dog Lab to watch ER.

8. How important were the following factors in your choice of this particular medical school?

a. General reputation of school
Yes, I was so excited Dupont was ranked #3 I set my house on fire.**

b. Amount of financial support offered
Very Important.

c. Nature of school's curriculum
As opposed to its demeanor? Not Important.

d. Ability of school to place students in particular residency programs
I didn't know I wanted to go to fancy-schmancy residency programs until I knew I could go to fancy-schmancy residency programs if I went to fancy-schmancy places. Of course, MD/PhD obviates the need for F/S med school, but still. Somewhat Important.

e. It was the only school to offer admission
But then again, it was the school I most wanted to go to. Very Important.

f. Friendliness of the administrator, faculty, and/or students
This is why.

32a. Regardless of your dependency status, please indicate your parents' combined gross income for last year (a rough estimate is sufficient).
Riiight. "$0"

35. How do you plan to finance your medical school education? Please enter a percentage for each applicable category to total 100%.
Now, is this "Work study" or "Award/Scholarship"? Some of my classmates list their occupation as 'indentured servant.' Split the difference.


I consent to have personally identifiable information released to my medical school. I understand that the medical school will not distribute this information to organizations or persons in any form that will permit personal identification of me.

You've got to be kidding me.

~~~~~
So, what does this survey mean? To me, it implies that medicine thinks rather positively of itself, and expects us to think positively of it as well. I left out some issue questions that ask about what we think about the future of medicine, but they struck me as grist for AAMC publications - "87% of incoming medical students think that physicians will be less well paid in the future - we must do something about it!"

It also tells me that the profession isn't ready for me, or that I'm not ready for the profession. Many of the questions asked about things that never even crossed my mind. I wonder what has changed since then. Have some of the questions become more relevant? Was the old survey sitting in my file, screaming, "ZSN has no business being in medicine"?


* Questions are edited for brevity, many are removed entirely.
** Dupont University, borrowed from Tom Wolfe, does not exist. I exist. Therefore, I do not attend Dupont Univeristy. Twit.

External genetalia - awesome

We're almost done, only the pelvis and perineum remain. In keeping with that theme, I give you the following image. This image is part of a series designed to contrast the simplicity (and overall awesomeness) of the cock and balls with the overwrought and complicated female reproductive tract. Unfortunately, the penis drawing (which consisted of a penis with many regions that were all labelled 'awesome') has been lost, only the vaginabeast remains:

Persistence

There is a quote in the anatomy lab:

Nothing in the world can take the place of persistence.

Talent will not; nothing is more common than unsuccessful men with talent.

Genius will not; unrewarded genius is almost a proverb.

Education will not; the world is full of educated derelicts.

Persistence and determination alone are omnipotent.


The implication is obvious - we need to work like crazy, or else we will fail, or at least fail to make our mark on the world. From here, my thoughts go in several directions. First, the whole quote, then a close reading of the quote as written (which is boring as hell), then how it relates to my thinking (also very boring).

Turns out, the remainder of the quote is, "The slogan 'Press On' has solved and always will solve the problems of the human race." This doesn't sound too bad, just a call to take control of your life. More significant (I think) are the speaker and the date, those being Calvin Coolidge and 1932.

Calvin Coolidge was president during the late 1920s. The stories of wealth , lack of foresight, and belief in unlimited prosperity from this period should have been ground into your mind in the 11th grade (as they were into mine). Reread Gatsby for a refresher. My PhD will not be in economics, but my understanding is that at least some of the causes of the greatness of the great depression were created or allowed to fester during Coolidge's administration. Wikipedia states, "Even in 1929, after nearly a decade of economic growth, more than half the families in America lived on the edge or below the subsistence level—too poor to share in the great consumer boom of the 1920s, too poor to buy the cars and houses and other goods the industrial economy was producing, too poor in many cases to buy even the adequate food and shelter for themselves." You may recall that the great depression began in Europe prior to it's American begining in October 1929. The European nations, understandably hard-up for cash asked Coolidge for relief and he replied, "They hired the money, didn't they?" You can see, he was not exactly a compassionate person. Telling somebody that was laid off because of a global depression and is incapable of feeding their family that they need to "Press on" is a kick in the teeth, plain and simple.


What does this actually say? I'm not talking AP English style close reading, I'm talking what's the meaning. The first sentence says that only persistence can be persistence. This in and of itself is meaningless. Nothing in the world can take the place of ice cream. Nothing in the world can take the place of road tar. Nothing in the world can take the place of some woman's dead husband on Law & Order. What is more common, unsuccessful men with talent, or bacteria in the colons of the unsuccesful men with talent? Perhaps we should read that as saying that the most common outcome for talented men is to be unsuccessful, in which case I would be better off sticking Crayons in my head Homer Simpson style than going to anatomy lab. I suppose I could always hope I'm one of the lucky ones (truly nothing in the world can take the place of luck), but unfortunately I'm pretty smart... It seems odd that an institution that exists to promote and sell (for an impressive price) education is claiming that the world is already stuffed with "educated derelicts." I'm reading the last line to say that the combination of persistence and determination combine to do... something. The concepts are omnipotent, but does that mean that potence is proportional to persistence x determination, or is it an all or nothing thing? What happens when two persistent people come into conflict?

Fortunately, this isn't a scientific pronouncement, so such close reading, while annoying, is not necessary.

This seems like a fairly benign, somehwat overwrought call to keep buggering on (or KBO as Churchill might say). It does make one want to reach for the Demotivators (this one and this one seem quite appropriate), but this in and of itself is more a reflection of my cynicism. I said before that this is "a call to take control of your life," but that's incorrect. The reason that I made that particular leap is that I conflated this recipe for success with my own. Mine is simply to internalize my locus of control. What does that mean? It means that I believe I am in control of my life. I realize that I can't control everything that happens, but I can control the probabilities that they will happen. I can't guarantee that I won't lose my keys (or cell phone, or mp3 player or any other small item), but I can do things that will greatly decrease the probability of that occuring, things like checking my pockets before I leave somewhere.

The same is true of grades. You can't control what will be on the test, but you have a pretty good idea what the questions will be, and you know how to study for them. A lot of work is required, yes, but also talent, genius, previous education, and a host of other traits - the wisdom to know when to ask for help, and the humility to actually make the request, for instance.

So what bothers me most about this statement is the idea that I am not in control off my success, and that the only way to attain success or power is to submit to a regime of persistence. As WSC might say, "Never give in--never, never, never, never, in nothing great or small, large or petty, never give in except to convictions of honour and good sense. Never yield to force; never yield to the apparently overwhelming might of the enemy." That is, know when to stop beating your head against the wall.

Head and neck anatomy joke

After finishing the practical exam.
I: Do you know why God gave us V1?
TA: Umm... why?
I: So you can tell when you're banging you head on the wall.



This won't make it funny, but the explanation for this joke is that sensation to your forehead is provided by the 1st division (1) of the fifth cranial nerve (V), thus V1. Yeah...

Sideline into the real world

According to Frank Foer of The New Republic, there is a broad international consensus that it will take Iran about 5 years to complete a nuclear weapon. Then he reports that the CIA says it will take Iran a decade.

Funny thing - the Jerusalem Post reports that the Israeli army (IDF) estimates that Iran will have nuclear weapons in 2008, that is 3 years. Consider the CIAs failure to predict the first atomic tests run by India and Pakistan. Consider their estimates, all their estimates, about Iraq. Recall who bombed the Osirak complex in 1981. Now, who are you gonna trust?

If I wasn't freaking out about anatomy, I'd be freaking out about this.

What residency are you thinking of going into?

The funny thing about studying medicine all day is that it forces me to think in such a way that I assume I will become a practicing physician. Getting my medical liscence for fun seems less and less likely, doing strictly clinical research seems more and more likely. This is partially Dr. Amy's fault, partially Piper's fault, and partially the fact that medicine is so damned seductive.

"Come... zsn... don't you want... to save a life?"

Fitting in

It's been an incredibly busy last week. We had the histology midterm today, and are currently deep into Head and Neck, with the exam on next Tuesday. Rather stressful. Still, we had a chance to go out for one of my classmate's birthdays.

To clarify things, my classmates and I actually get along pretanaturally well. for instance, this was the third time we've gone out to eat and had to split the bill by everyone paying cash. Normally this turns into a debacle as no-one has money and the person that ends up paying gets stuck paying way too much, but with this group, it was smooth as silk.

We were joined by three second years. Two of them are the TAs, who have calmed down considerably since the begining of head and neck. It's now much clearer that their threats are in jest, and they really do wish us well. The third second year flunked anatomy, and so she is retaking with us. It's so incredibly helpful to have someone like that around since she knows the ropes, is one of those people who knows everyone,* and is quite sympathetic to us because we are in the same boat. She's obsessed with setting my overwhelmingly male class up with the incoming first years and her class of second years. I think it's rather cute, but appreciate that getting set up with people will also mean that I get to meet people.

Whenever we eat, MSTP with MD (or perhaps messed-up with normies), the rivalry always comes up. The problem is that people with very different career plans are in the same classes together so there will always be some cross talk, but understanding that doesn't make it any less likely to occur. One of the reasons I chose to come here is that the MD/PhD program here comprises a REAL MD and a REAL PhD - that is, full degrees, with nothing cut out, and very few relaxed requirements. In one of my first posts, I mentioned seing a group of MSTPs in a second year medical class describing their patients, and noted that the preceptor didn't realize they were MSTP until they told him they were going into the PhDs rather than into the clinical years of training (3rd and 4th years of med school). I therefore take it as a priority to fit in with the medical school class.

Thus, it bothers me that the TAs talk about playing 'spot the MSTP.' I suppose the year ahead of us was incredibly cliqeish in class the first year, and may have been haughty, but the thing is that we too will stick out. Having taken anatomy and histology, we won't be taking those classes with our MD counterparts. Physiology and Touchy-Feely I may help make up for it, but if we're not in there bitching about our anatomy readings, it could be difficult to connect. Ultimately, I think I care more about getting some friends here than having my administrative quirks remain unknown.

* Part of the reason that she knows everyone (other than the fact that she is rather outgoing) is that she failed anatomy. Everyone knows that she failed anatomy, therefore she knows everyone, and seems to enjoy her noteriety. She described me as the 'most sarcastic member of the class' a high honor, seeing as how we seem to have been admitted on the basis of most sardonic wit.

Head and Neck I

This unit start was particularly tough. Partially it might be that head and neck are an extremely complex region, but more importantly, the proff and the TAs seemed upset for some reason.

I think my attitude about the last test, and that of my classmates ticked off the TAs. We dismiss the difficulty of the class they're took, even though theirs was more in-depth. They go out of their way to make things easy for us, and our ingratitude and whining won't and shouldn't earn us any points. I need to do something about this.

The problem is that the amount of material seems overwhelming, and if you add in a hostile learning environment, I might as well start packing now, as I (half-jokingly) threatened to do before lab today. However, lab seemed to go much better, everyone was calmed down, smiling and laughing again and proud of our ability to pick things up.

Even I'm amazed. Eight hours ago, I knew nothing about the cranial nerves. Now, I know their names, numbers, foramena, and something of their innervation. Cold.

Anatomy update

Just finished the lower extremity (thigh, leg, foot, bits of hip that have to do with moving same). Test was on Monday. Got an 86% overall*, which I was kind of disappointed with compated to my 93% on the first exam, but the TAs pointed out that this exam was purposefully made more difficult, and it's a pass/fail class with a 75% threshold, and most people would kill to get our grade distribution. According to them, the test was about relationships and anatomical reasoning, which is basically prequisited on us having the anatomy cold - to have done as well as we did indicates that this was the case.

Now on the head and neck. We're getting a compressed version over the next week and a half (test on the 2nd). So, rather than posting, I ought to be reading my anatomy book and browsing my Netter's. Best of luck, all.

*81% on the written, 100% of slide id, and 89% on the lab practical. The slide id and practical are more identification oriented, thus justifying my reasoning.

Abortion

Like Bill Clinton, I believe abortion should be safe, legal, and rare. Putting aside how many that should be, if you had asked me to guess this morning, I would have said that there are about 100,000 per year. I was off by a factor of ten.

Turns out there were about 1,293,000 in 2002 (via AS).

This turns into an incidence of 20.9 abortions per 1000 women aged 15-44 per year. I have no idea why the statistics are presented in this fashion. It would be more accessible to present them as 2.1% per year, which translates to a 50% reproductive lifetime risk of having an abortion.^1 Compare that to the 13% total rifetime risk of developing breast cancer (NCI).

We watched a video in class today^2 that compared embryonic development of different vertebrates, showing how wildly different structures have a common origin. It struck me that all the embryos that were presented in this rather upbeat, positive video were, in fact, dead and never going to complete the developmental journey that they were being used to celebrate. I'm grateful to the embryos and their families for giving me the opportunity to see this, and I thought the video was outstanding overall, but that twinge of sadness...

^1 You wanna quibble over statistics? Ok. Not likely to be productive, but...
Quibble 1: Spock suspects that the eggs are more in one basket, i.e. the same women keep having abortions. This seems to be the case in New York City, but overall it looks like most women are first timers.

Quibble 2: Harpo asserts that relatively few abortions are done on upper/middle class white women. Clearly, gender is a key factor in who gets abortions. Minorities are over-represented. Those who are in poverty or near poverty receive about 60% of abortions.

Clearly, there are more abortion statistics that I can keep track of, but even if 'only' 1 in 3 women will have an abortion, that's still a ton of people.

^2 I believe the video was "Oddesy of Life" from NOVA

Sigh

This blog is intended to be half personal, half professional - that is, my reflections on my day to day professional student life should be the majority of the discussion. Here's something more personal - my personal pictures, on flickr, just to give you some visuals.

http://www.flickr.com/photos/patientetherised/

By the way...

You may find yourself asking, "What's a medical student doing drooling over basic molecular biology papers."

Well, I'm a little MeST uP. (Pronounced "messed up").

You may find yourself asking, "What does that mean?" This is the short of it - an MD takes 4 years. A PhD in biology should, according to NIH, take 4 years. An MD/PhD takes (about) 8 years. At the end of this time you walk out with two doctorates.*

You may find yourself asking, "What can one do with an MD and a PhD?" The answer is this: Anything you fricking want. Seriously - you want to practice, go practice. You want to teach, go teach. You want to do research, of any kind, do so. You want to do some kind of bizarre hybrid in an effort to make all the years sunk into your degrees pay off? Go for it (It's difficult to do this well, but not unheard of).

*They take this very seriously at my institution. When you defend your PhD thesis, you do a hooding ceremony, graduation, parents come out, blah blah blah. When you graduate from Med school, you do a hooding ceremony, graduation, parents come out, blah blah blah. No requirements for either degree are waved. The idea is that we actually are earning two degrees, not two chunks of degree.

RNA pathology, dangit

One area of research that I've thought about getting into is non-canonical RNA, that is, RNA which is not tRNA, nor rRNA, nor mRNA. Recently, we've seen big developments in RNA interference (RNAi) where you add RNA to a cell to get it to shut down production of the complimentary gene (Footnote 1). That was fairly interesting, then I stumbled onto microRNA (or miRNA), which are small RNA produced naturally by cells which fulfill various tasks. Most of them are unknown, but one is known to be involved in fly eye development. On my interviews here, I talked to someone working on long non-translated RNA, and also varients to the old standbys. For instance, there are multiple different versions of each of the tRNAs in humans -> what do they do, why do they exist?

Anyway, I had an interest in RNA pathology, that is, finding RNAs that cause or are involved in disease. People laughed. They said RNA was either too fundamental (tRNA, rRNA) or too low copy (miRNA, other non-mRNAs) to have enough effect to be seen on a human scale. Well. Check this out. In summary, there is a cluster of microRNAs (mir 17-92)that, in combination with other oncogenes (namely c-myc) cause tumours to grow faster (Footnote 2). Very exciting. However, it doesn't seem that they know how this newly relevant miRNA oncogene does its thing. Maybe someone (hint-hint) should investigate.


Footnote 1: A short explanation of RNAi with most of the detail stripped out. DNA exists in a double stranded, antiparallel condition, like so:

W: Start->AGTCGTACC->End
C: End<-TCAGCATGG<-Start

We arbitrarily label the strands W and C so that we can keep them straight. Say that W codes for a complete gene, the sequence of which is: AGTCGTAC. When the gene is activated, an enzyme comes along and transcribes the gene, producing a transcript. The transcript is made out of RNA, which uses "U" instead of "T," so it would be:

Start->AGUCGUACC->End

This piece of RNA is called messenger RNA or mRNA, it completes its function by meeting up with the ribosome, which translates the RNA into protein, according to the genetic code. This particular gene would produce a protein whose sequence is Serine-Alanine-Threonine. This has all been known since the mid sixties, major snooze factor.

Here's RNAi -> is you introduce RNA that is complimentary to the mRNA, the gene is shut down. What does this mean?

The mRNA is: Start->AGUCGUACC->End
The complimentary RNA would be: Start->GGUACGACU->End
Wait, that doesn't pair at all! Except that, it does because the pairing is anti-parallel, like so:

The mRNA is: Start->AGUCGUACC->End
The complimentary RNA would be: End<-UCAGCAUGG<-Start

Note that the complimentary RNA bears an eerie similarity to the C strand of the gene, such that if you expressed the C strand, you would produce that complimentary RNA.

So, you have the mRNA, and complimentary RNA. What happens next? They base pair, of course. The product is double stranded RNA (dsRNA). dsRNA is never encountered in multicellular organisms, except for in viruses. Therefore, whenever your cells see dsRNA in them, they interpret it as viral RNA. They then produce enzymes that destroy the mRNA of the gene, and may completely shut it down gene. This is called interference (hence RNAi). In plants, once a gene is shut down, it never comes back. In humans, the gene is only shut down as long as you keep adding the complementary RNA to the cell, and the amount of interference is proportional to the amount of complementary RNA you add. This is great for experimenters, in that you can see what happens if you have a range of expression of a gene, as opposed to the simple on/off allowed by genetic engineering. It is somewhat bad for patients, because if you are shutting down a harmful gene by giving the patient complementary RNA, the effect wears off quickly, and you have to give them a lot of RNA to see an effect (people are trying this as we speak, btw).

Footnote 2: He L, Thomson JM, Hemann MT, Hernando-Monge E, Mu D, Goodson S, Powers S, Cordon-Cardo C, Lowe SW, Hannon GJ, Hammond SM. A microRNA polycistron as a potential human oncogene. Nature. 2005 Jun 9;435(7043):828-33.

PMID = 15944707

I applied to CSHL for grad school, didn't even get called for an interview. I know who Hammond and Hannon, and I wanted to work for them, and if I were... sigh.

Update:

I read the paper. Not bad. I mean, there are holes you could drive a truck through, but I'm still hugely excited. They want to rename their gene oncomiR-1 - that's oncogenic micro RNA 1. Woo. It's like Ras in 1982.

In Soviet Russia...

Sorry, couldn't resist.

...not evil

Classmate 1: I need to relax this weekend

Classmate 2: Need a drink

C1: Smoke some weed

C3: Need something stronger. Get some heroin.

I: Sure, find the saphenous vein. Median malleoulus, 2 fingers up, 2 over, put in a line. You can run 500ml of heroin a minute.

C3: That's just twised.

I: Well, we haven't yet sworn to use our powers for good.

What's in a leg?

When I tell people (as I just did) that we described the entire anatomy of the leg in three days, many ask me, as my friend Marc did, "is there much anatomy in the leg?" Ummm, yes.

How much?

Bones: 28 plus
Well, the hip (os coxa) is actually 3 bones, the illium, the ischium, and the pubis (aka the pecten). There's the femur, tibia, fibula, then the foot bones - talus, calcaneus, navicular, cuboid, 3 cuneiform (medial, intermediate, and lateral), 5 metatarsals, 14 phalanges, and don't forget the patella. Each bone has several parts which are signifiant because muscles attach there, or they articulate with other bones, e.g. the head of the femur, which is the ball to the hip's acetabulum, which plays the part of the socket.

Muscles: about 70
I'm not naming all of these, but from going through my atlas, there are about 70. Think about it, you can do some pretty amazing things with your leg, and for each of them, several muscles have to work together, many of which are unique to that movement. Something like walking is a lot more complicated than it seems, insofar as some little thing like being able to flex your toes when you push off makes your walking a lot more graceful.

Nerves, blood supply, venous return, blah blah blah: Lots more
Anyway, my point is not just that I have this really long vocabulary list that I have to transcribe to my 3x5 cards, quite the opposite. Flashcards do not help, because I have to be able to identify these structure on any body in the anatomy lab, in anatomical cross section, on x-rays (or CT, or MRI, or angiogram, or, or, or), and tell how they interact (e.g. illium and psoas muscles form up to make the illiopsoas muscle, which inserts on the lesser trochanter of the femur, the blood supply is whatever, the nerve innervation is such and such with a given set of spinal segments), and how they can and can't be injured (i.e. a fracture at the head of the feumr is unlikely to disturb a muscle like illiopsoas that inserts lower in the bone - at the lesser trochanter).

People who know me know that I sail through most academic things. They may wonder why I have to study constantly for this, and this is why.

Anatomy update

Just finished the third week of anatomy. Started with a test on the 'upper extremity,' and then we covered the entire 'lower extremity' (what a normal person might refer to as the 'leg') in 3 days. I've never studied so much in my life. On the other hand, I have exactly one responsibility - pass anatomy. If I'm doing that, nothing else matters (including getting my window fixed). Thus, I can justify sleeping 9 hours a night, because it improves memory.

Anyway, despite doing the leg in three days, the test isn't until next monday, so we're going to spend the next week being lectured by leg surgeons, radiologists, and other clinical types on the leg. This is good partially because it helps you remember, but it's bad in that whatever the clinical guys say is testable. For instance, an orthopedic surgeon came in and told us about different types of nerve damage - nerves can be bruised, they can be cut, or only the conducting part (axon) is cut, while the insulation (epineurium) is fine, or it can be pulled out at the spine. Then he chuckles and tells us, "Of course, we don't call it that, we don't want anyone to understand." All of a sudden, we have to know neuropraxia, neurotmesis, axonotmesis, and avulsion (in that order).

You're in the city now!

I've got to eat just like anyone else. So, despite my dissection schedule, I put aside some time today in order to go grocery shopping. I unlocked my car, opened the door, and was shocked to find some kind of white powder sprayed all over my seat. On closer examination, I realized that the powder was actually the facets of small, otherwise transparent cubes. Then I noticed that the passenger side window was missing.

I circled around to the passenger side, and gaped at the fractured remnants of the safety glass. I looked inside and saw that window sprayed all through the car. Damn.

I looked around the inside, trying to find something missing. Harry Potter on tape - still there. Car CD player - still there. Change - still there. Then I remembered. I had been leaving a few bucks in the cupholder to pay tolls with. That was the only thing missing.

Someone broke my window for $3.

On the other hand, I'm keeping the brick they tossed in as a souvenier. Also, my roommates helped me clean up, and we went out afterwards for diner food to celebrate. Since I've been having trouble making friends with them, the progress seems worth the cost. One of my roomates thought the glass actually looked rather pretty, and insisted I get a photograph. The almighty brick lurks in the background.

High yield

So, the first week I thought to myself, "It can't possibly be hard enough to justify all the study time everyone else is putting in." Yeah. Now, I'm putting in that much time, and more. The hackneyed metaphor seems most appropriate - we're drinking from the firehose now. Time to only pay attention to what's helpful, time to start living off of ramen noodles, time to get "high yield."

So, what does high yield mean? Means the source that will give you the answers to the most questions on the boards for the least amount of work.

What are these "boards"? A series of tests you have to pass if you want to be a doctor. The first test (called, 'steps' for whatever reason) is an overarching final for everything in the first two years of medical school.

The class that I am in is high-yield. I will study high-yield materials, and even higher-yield supplements.

I think back to undergrad, a mere month ago. I always thought the question, "will this be on the test?" was so undignified. I was always trying to learn more, to get outside the material, and play around with it. There simply isn't time here. The pace of the curriculum seems to demand memorization (aided by as much anatomical reasoning as I posses). Elaboration is provided by clinical considerations, which are memorization fodder, as well as aides in memorization. One set of material reinforces the other. Anyway, it's all spoon-fed. I guess otherwise it wouldn't be high yield.

ID!

I have a whole new life - new student ID, new swipey RF "ass-badge" to open doors, new bank card, new keys, now - first hostpital ID. Exciting. I am a "student intern." Ooh. Means I can go get scrubs when my laundry is running low. Also means I got a nifty little card that explains what all the hospital codes mean. For instance, at my hospital:

When they say: Dr. Cart
They mean: Cardiac arrest

When they say: Dr. Suess
They mean: Infant / Baby security alarm

When they say: Dr. Strong
They mean: Patient disturbance

They also gave me a handy mnemonic to use whenever Dr. Red (a fire) comes calling... R.A.C.E.R. As if I don't have enough acronyms to memorize.

Don't ask me what any of this means. As I have previously indicated, I am not a doctor (and it would be illegal for me to claim otherwise!)

Legal immunity

Every normal person has been vaccinated. It is a requirement for getting into kindergarten, elementary, middle, and high schools. When I graduated from HS, they gave us empty leatherette cases, and told us to go to the commons to get our diplomas, and our immunization records.

Proof of immunization is also required to enter as an undergraduate. Ergo, an undergraduate diploma is proof of immunization. However, in my packet of 'little things to do in the two weeks before school starts,' immunization forms! No problem. However, they indicate that, rather than proving that I have had my shots, I need to prove that they did some good via blood titer.

Now, I'm not a doctor, yet, but something about this strikes me as odd. Under what conditions could someone be immunized, yet no longer be immune? I'd believe that the polio shot my mother got 40 years ago is starting to lose its impact, but my shots are much younger. The only way I wouldn't be immune would be if I had no immune system whatsoever. Anyway, I am, indeed immune to MMR, do not have tuberculosis, etc. thus I am here, and can get my hospital ID (see above).

Body rap

First day of anatomy lab today. First we got our bone sets - half of a body, plus the skull. I was forced to admit that I don't know the names of most of the bones during checkin, but I got some help, and I don't think I'm likely to forget them after this summer. I dropped the skullcap on a dissecting table, and one of the TAs said, "if you had to drop one, that would be the best." The bone was undamaged.

After the bones, we had a quick ceremony to honor the deceased, then wrapped the bodies. First the TAs showed us how. They just unzipped the body bag that it came in, and here was this naked guy, his hands and ankles tied with coarse rope. They lifted the body, whipped out the old bag, and brought in the new one. They didn't give any indication that the body was fragile, or something that could be broken - they moved it around as you would a living body, yet when I tried to splay the fingers on our dead woman, they were stiff.

To keep the bodies from decomposing, we wrap them in a rags (actually cut bits of sheets) that are dipped in phenol. Phenol doesn't smell as bad as formaldehyde, but it still gives you that smell of death. I've taken up swimming in hopes that the chlorine will either react away or cover the phenol. Phenol, by the way, is a local anesthetic that also causes irritation - i.e. it deadens the skin, then messes it up.

After class I went back to the lab and got out my bones - we have reading this week on anatomy of the upper extremety (what normal human beings might refer to as 'the arm'). I figured it would be helpful to have the physical bones in front of me while the textbook talked about them. I was amazed at how the bones articulated... by this I mean, I was surprised at how closely they fit together. Somehow, I had it in my mind that the joints would be large, fluidy things, and thus the marriage between two bones would be more a function of connective tissue, rather than physical connection. This is not the case.

I feel like I should be diving into the more researchy stuff, or getting into some kind of social thing, but I keep telling myself I don't know how busy I will be...

Cruel Summer

I just finished my first real day of classes. The more I learn, the less intimidated I feel, yet the workload is immense. The instructor seems friendly (e.g. he invited us out to his place to watch the fireworks on the 4th), and I guess the lowest anyone got last year in the class was an 82% (which, like anything between 75-100 turns into a P), but I'm still somewhat apprehensive. There's a ton of stuff to learn... At least this is my only responsibility at the moment. Later this summer, we're going to watch an autopsy. Seems like a good review, something I should get a feel for if I intend to hang out with the dead for my whole life.

We had a talk with a woman here who acts as a sort of medical ethics person - I think I'd like to hang out with her a bit.

One good thing

I know what kind of doctor I want to be -

The kind that snorts cocaine off the huge, fake, naked breasts of his female patients.

*, a.k.a. Thoughts on privacy, BS

I'm not sure I want the people in my program reading my blog. I certainly don't want to have my awareness that they're reading my blog cramp my writing. I don't expect to get kicked out of the program, but this business is all about recommendations. If I want my next job to be in Bethesda or Baltimore, rather than Billings or Bismark, I need to get good recommendations. If I'm gunning for a medical residency, do I really need all my skepticism held against me?


What does privacy have to do with the claim that my institution invented the white coat ceremony? Well, if my institution really did invent the white coat ceremony, all of a sudden the pool or people I could be narrows considerably, from the ~16000 incoming MD students, to the much smaller number at my institution. It would be like saying our dean is a woman, or that I can't wait to count all the sunny days and see if Phoenix really does have more than 300 per year.

I'm vaguely confidant that I wont get found out because I'm sure that half the medical schools in the country are passing out the same palaver to their students. Most aspects of medical practice are like the internet - everyone says they invented it, no one says they control it.

Please treat this as a formal request for privacy. I don't want to be found, don't look for me, the momentary satisfaction that you gain is not worth the possible damage to me.

Bad news on the medical front III

I haven't had a single medical class yet, and already I'm acting like a doctor. I told my uncle (the one from BNOTMF1) that he should look into taking two more drugs - just pulled them out of my ass. I know like, 10 drugs - what are the odds that I know one, much less two, that will help him, especially absent anything other than talking to him?

Second, I suggested that two of my other family members might have some kind of social anxiety disorder, and recommended that they consult with mental health professionals (while hinting that drugs could 'make them better').

Third, I have been getting giddy about my white coat ceremony. Some things, they celebrate when you leave, like graduation. For medicine, they celebrate when you show up. They put on a big pseudo-religious (or religious) ceremony, administer the hippocratic oath and symbolically induct you into the priesthood with your white coat (the modern oath is a bit more PC).

With all my heart, I realize I should just forget about it, collect my white coat when necessary and get on with my life. But then I said, "don't I want to meet my classmates?" Of course! And what better opportunity? (Don't answer that). So I was like, "Oh, I'll invite my mom!" (She'll be in town, moving me in). And then I got an admitted student mailer, and they're like "You can invite up to five people - they get really nice invitations." And I'm thinking, "cool, nice invitations." By they way, my institution claims* to have invented the white coat ceremony, so you just know it's going to be overblown.

Then I spent all afternoon trying to figure out if I want a size 38 or a 40, and whether I should get long, or standard size. Yeesh. The final answer, by the way, is 38 long. Why? 1) I'm probably not going to be wearing the coat over my winter jacket and 2) When I was a little kid, I always wanted a cape. In fact, my entire fascination with science and medicine might be traced to the fact that these people get to wear cape-like things every day as a matter of course. A longer 'cape' enhances the super-hero experience. Although, if I were to pick a super power, it would be "making people do whatever I want by scratching them behind the ears"** as opposed to, "pushing drugs."


** We're going to have a facebook, and one of the questions was, "What super power would you have, and what would your name be." I'm 'catnip' if you must know. It was either that or have the super power of always having tea no matter what, and the tea is really good (I was going to call myself, 'The Teabagger' so this one obviously wins on the name). Seriously.

* This is getting it's own post, as it sprawls into a larger issue.

Bad news on the medical front II

And I think, maybe we're just toys of the pharma industry... they obviously know what they're doing. They wouldn't be bombarding us consumers with ads if they didn't think it would have an effect on sales.

To kind of fit in with this, here's a look at things from the perspective of a drug detailer (i.e. a sales rep)

What if I'm just one of this guy's stereotypes? Somebody hold me.

Bad news on the medical front I

I've been asked (in comments below) why physicians in general are unwilling to 'stand up' to their patients. That is, when someone sees an ad on TV and they come to the doctor's and ask for the drug, why does the doctor roll over and give them the drug?

I actually ran into a counter-anecdote, in that my uncle's physician refuses to perscribe drugs that he suggests, apparently for the bloody-minded reason that my uncle has suggested the treatment.

I'm going to disregard this anecdote, partially because it's an anecdote (even if true it proves nothing), and partially because there's a question of whether my uncle's ideas for treatment are good - he goes in for alternative medicine treatments that are untested, both in terms of safety and efficacy.

So... let's go to the literature:
Mintzes B, Barer ML, Kravitz RL, Kazanjian A, Bassett K, Lexchin J, Evans RG, Pan R, Marion SA. Influence of direct to consumer pharmaceutical advertising and patients' requests on prescribing decisions: two site cross sectional survey. BMJ. 2002 Feb 2;324(7332):278-9., PMID: 11823361 (free full text here)

In summary:
1. About 74% of patient visits result in a drug being prescribed - this is the accepted figure.
2. Patients that ask for drugs in general are more likely to get drugs
3. Patients that ask for advertised drugs are likely to get the drugs they ask for.

So, the observation that physicians bend over backward for their patients checks out. However,

4. When patients asked for drugs, in general or in particular, the physician was more likely to be 'ambivalent' about the treatment.

What's going on here? I can't find a study on that. The establishment guess would be that it's either business or law at fault. If I won't deal to you, you'll find someone else who will -> I lose business -> I starve. If you suggest a treatment for X, I don't treat you for X, and then you die from X, I get sued.

Of course, the study is all self-report, which causes all kinds of difficulties. Still, this is a definite plot hole in the 'physicians think they're gods' story.

A man walks into the doctor's office

The doctor says, "It gets really boring doing physicals on healthy guys."

Seriously, though, I had to get my immunizations updated for med school, so I went in. I have nothing of interest to report. They're letting me rate my own TB test - apparently my medical student status qualifies me to feel my arm for a bump. Also, the nurse was telling me how to do the various shots (e.g. a TB test is subdermal and only to produce a weal).

I did not badger or bully my doctor, though I should have... I guess in situations where nothing seems wrong I'm not excited to go looking.

Medicine is a very seductive thing...

I am very suspicious of medicine. Let me say this carefully, so there’s no confusion. I believe that virtually every physician believes they are motivated to do good, and believes that they are doing good. I accept as a fact that modern, western medicine is the only discipline of healing that is worth anything. I will begin, very shortly, training to become a physician.

However, there are many aspects of medicine that trouble me. The first is the streak of arrogance that runs through the profession. The white-coat fetish is a good example or this from a stylistic standpoint, but this self-confidence does substantial damage as well. The Tambocor debacle chronicled by Thomas Moore in _Deadly Medicine_ is a prime example of how doctors will supply patients with treatments that are scientifically known to be hazardous because they think they know better.

There are other critiques, problems that are failing to surface because my brain is cloudy, but these will do. The trouble is, knowing what I know, I am still walking into it. Of course, scrubs don’t have pockets, so you have to wear a coat so you’ll have somewhere to put your pens. Of course you wear it to go to lunch, otherwise you’d have to change. Of course you call yourself Dr., otherwise people will be confused. Etc. etc.

Falling into this is aided and abetted by some of the truly impressive things physicians do. When I revisited the md/phd program, I sat in on a physical diagnosis class, which is where second year students go around the hospital interviewing patients and then present the cases to the instructor. This is essentially what they will do in their clerkships and residencies (and practices) except that they aren’t the ones treating the patients. I sat in on the part where they presented their cases, and I was wildly impressed by the amount of complexity they had mastered, both in the patients and the background material. It gives you the feeling that medicine is an intellectual pursuit.

This isn’t necessarily the case. As a caveat, I lack facts in this area, and such facts would be difficult to acquire. However, I have been told, and it seems reasonable, that medicine is primarily pattern recognition, which requires a good memory. The memory may be either broad or deep, depending on whether the physician is a specialist or generalist but not much critical thinking is required. A ‘good doctor’ may be one that is more of a hand-holder than an intellectual mastermind.

The apparent intellectual parity between medical practice and medical science makes it acceptable to become more and more the physician. One of these disciplines comes with a lot more prestige. A practicing physician can get lunch money from a five-minute consult. Scientists are generally stuck begging from the feds. To add insult to injury, if an M.D. and a Ph.D. are both competing for a grant from the NIH (the largest source of scientific largesse on the planet, part of the federal government), the M.D. is more likely to get it.

Finally, beyond intellectual difficulty, beyond prestige, is success. A practicing physician will, in an average day, treat or cure multiple sick people. They are surrounded by success. Conversely, most research projects fizzle. As I spend season after season chasing a seemingly impossible scientific goal, who is to say that the easy success of medical practice won’t lure me to spend less and less time in the library?

Today, at least, I say I’m sick of getting all A’s. I’m sick of not studying and getting 94%. I want my successes to mean something to me, and the only way they will do that is if they are surrounded by failure.

OK – that’s a helluva long post. But I wanted to get that all down in writing, so if I start being a jerk in the future I’m on the record saying otherwise.

Chomsky

For the next two weeks, I am still an undergraduate, which means that I am taking courses intended to broaden my mind. One of them, which really isn't too bad, is Cognitive Psychology. We discuss a lot of experiments and critique the conclusions drawn out of them.

Today, we talked about language. Noam Chomsky enters into this, and became famous, for critiquing B. F. Skinner's book, "Verbal Behavior." Without getting into this too much, Chomsky mischaracterized Skinner's argument (It is generally felt that he either didn't understand it or never read the book), and then attacked this straw man.

This episode is seen as epochal in cognitive psychology (it's mentioned in the 1st chapter of our textbook), because it was part of the decline of behaviorism.

Anyway, one of Chomsky's arguments for why language must be inborn is that if you take the meaningful, grammatical sentence "John drove the car into the garage," you can shorten it to "John drove the car," to make another meaningful, grammatical sentence. However, if you take the sentence, "John put the car into the garage," and shorten it to "John put the car," the resulting sentence is not meaningful.

Chomsky points out that children don't make the second sentence - they seem to know better. At this point, I got confused, becasue I'm sure I've heard children making homologous mistakes. So I asked the prof, "Are there any experiments that back this up?" And he said, "Of course not!" And I said, "I wish you would have told me there was no evidence for this before I put so much effort into trying to believe this."

That's the problem with psychology, and the attached pseudo-disciplines (like linguistics) - it's not all science, but it's not all non-science either. You just have to be clear on which is which. As an English major, I'm used to being in circumstances where we have to argue a bunch of vague, untested, untestable statements, and as a biochemist, I'm used to being in the exact opposite circumstance. I would just rather know which set of rules we're playing by.

A man walks into a bar

He drinks 6 Newcastles, 4 shots of Jack Daniels, hits on the waitress unsuccessfully, takes his wedding ring off, tried again and fails, drinks 3 more shots, drives home, beats his daughter for coming home late, and cries himself to sleep realizing that he hates his life.

This and other realistic endings to jokes at: ::Something Awful::