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::

Terrible jokes

Apparently, in the 1950's there was a fad where people would tell jokes with formulations like, "In America, you X the Y. in Soviet Russia, the Y X's you."

e.g. In America, you stand in line. In Soviet Russia, the line stands in you.

In America, you disapprove of the government. In Soviet Russia, the government disapproves of you.

In America, you go people watching. In Soviet Russia, the people watch you."

Those were mine. Some I stole from elsewhere are:
# In Russia is freedom of speech. In America is also freedom after speech. -- Yakov Smirnoff
# In America, you watch television. In Soviet Union, television watches you.
# In America, you check books out of library. In Soviet Union, library checks you out.
# In California, you can always find a party. In Russia, The Party can always find you. -- Yakov Smirnoff

There's a link, of course.

New (re)sources

FYI, I also like (and recommend you listen to) -

The McLaughlin Group
Yelling and screaming, but a very different perspective from any other source I have. Definitely gives you something to talk about at the dinner party. You can even watch the video if you're willing to let RealPlayer eat your soul.
::The McLaughlin Group::

Derbradio
John Derbyshire .mp3s.
My roommate: I like listening to him. I don't know why.
Me: Because he's an unreconstructed paleocon with an English Accent.
::Derb Radio on National Review Online::

Latest Outrage

From the Chicago Sun Times:

Alice and Ken Heckman each start their morning by cracking open a plastic tray
with scores of pills in a rainbow of pastel colors.
Between the two of them, they gulp 29 pills every day: a regimen of 14 drugs, with
a chaser of dietary supplements. Here's the curious part:
They feel pretty hale for people in their early 70s, working around the house and
volunteering with several community groups.

The rest of the story is here.

Let me see if I've got this straight - people feel well, and they take meds. They take meds, and they feel well. Is it possible that the medication is... A contributing factor in their continued health?

The rest of the story is less ridiculous, yes. But it would be nice to know what they're taking, other than the fact that they have 14 drug perscriptions between the two of them. According to the story:

She has well-controlled diabetes. He has worked his way through heartburn,
arthritis, an enlarged prostate and occasional mild depression.

O.K. At one drug per disease, that's 5/14. I would assume that at least one of those diseases requires multiple drugs (I'm guessing diabetes). Add in drugs for heart disease and you're almost there. The most effective heart regimens contain multiple drugs - diuretics, aspirin, drugs to slow the heart etc. etc.

From my limited knowledge, I guess that Americans might be overmedicated, in that, for some, taking fewer drugs would increase their quality of life. But that's just a guess. I would also guess that there are quite a few undermedicated Americans, who lack access to medical care.

I bash drugs companies relentlessly for their marketing, for their creating of me-too drugs, for their patent extending games, etc. I also bash physicians for not being better informed, not standing up to their patients, etc. But... if those drugs are what the Heckman's need to feel hale, why not leave them be?

Questions?

And then...

Worst time ever to create a blog. Swell.