Health Care Reform

There's a really excellent editorial about health care reform by William Saletan in Slate this morning.

I'm going to try out my new running shoes now. It's 53 and sunny -- it should be a good one!

Blahs

I don't know if it is apparent from reading this blog, but I've not been enjoying life that much of late. I don't know if this is normal for the transition to PhD-land, and it will get better as I progress further, but I've been having a serious case of the grad school blahs these past two months.

I'm still glad I'm doing this program (I think), but being the first person to combine a particular PhD program with the MD is HARD. I'm getting jerked around about my funding. Nobody knows how I should be balancing course work and grad school work, so I'm getting pulled in multiple directions. Many of the master's students who are fellows -- the people who are in my classes and who I spend most of my time with -- treat me like garbage. And I am seeing my med school classmates move on and start the process of becoming doctors. I feel like I am being left behind.

Add to that the prospect of residency at the end of all of this, and thinking about having to relearn all that material, is sobering at best. Actually, the relearning doesn't bother me so much. It's being forced to work with said fellows who treat me like garbage for ANOTHER 3-4 years as a resident that I think I am dreading most.

So, I am writing this post to remind myself of things (besides sleeping) that still make me happy. I will try to think of ten of them.

1. The feeling I get after a swim where I've showered and I walk outside, and I feel all warm and toasty in the cool air.

2. Making dinner together with my husband every night.

3. Reading 5 pages of Anna Karenina before I go to bed each (most) night(s).

4. Doing biostats problem sets. Becoming completely focused and lost in the subject. Solving new problems successfully.

5. Walking to school. If I get up early enough there aren't hoards of undergrads around and it can be very peaceful. (Otherwise it sucks.)

6. Talking with my friends (an increasingly rare occurrence). I said TALKING, not complaining.

7. Getting the phone call from my husband that he's at the zoo and will be there to pick me up from school in 5 minutes.

8. Writing blog posts (thank you commenter #1)

9.


Well I can't think of anything else right now. Sorry.

Back in the day

I remember when I was working as a research project manager before I came to med school.

There were these other project managers who had an office on a different floor. The office was shared by several of them. As was customary, one day they received a name plate for their door.

That didn't last long.

You see, a bunch -- not just one -- of the attendings on the floor objected to the fact that the names of the project managers on the name plate were in a larger font than the name plates on their doors. This was completely and utterly inappropriate. Afterall, they as ATTENDINGS had worked hard in the past (obviously harder than mere project managers could ever dream) and they therefore deserved to have their names in the biggest font.

So the name plate came down.

*****

Now I suppose I should relate this in someway to my experience being a medical student, and what it must be like to work with a bunch of narcissists.

But I won't. I'm sure you all can imagine just fine.

I'm supposed to add that *not all* doctors are like this, so that any doctor who reads this can take comfort in thinking, "Well, some doctors are jerks, but THAT'S NOT ME."

All I can say is that I promised myself I would never be like that when I (finally) became a doctor. I would rather die than be that kind of person.

I wonder if they used to feel that way too?

Mentorship

So a few weeks ago I wrote about a seminar I went to about finding a mentor. During the seminar, one of the residents said that she'd been having trouble finding a mentor in her area of research. And her area of research was my area of research.

I decided that I might be able to help her find people to talk to in this area, so I sent her an email after the meeting.

We met, and it turned out that she basically hadn't talked to ANYBODY who I knew. So I gave her some names, and we chatted for about 30 minutes.

Afterward she said, "I am SO SORRY that I wasn't able to buy you coffee."

I was confused. It was 6PM. Coffee? Huh?

So I asked, "Why would you buy me coffee?"

"Because a resident is always supposed to buy her med student coffee."

Ouch.

See, I hadn't looked at it at all like that kind of conversation. "Her" med student? To me, we were speaking to one another as researchers who are interested in studying similar subjects.

So I said, "Oh, well it's not like you're MY resident now. If anything according to that logic, I should be buying you coffee since *I* am giving *YOU* information, not the other way around."

She said, "But the resident is ALWAYS supposed to buy the med student coffee."

I guess I was being overly optimistic that she'd be able to relate to me as a person and not simply as "her med student."

:-P

2 sides of the coin

In the elevator, some of the Master's program students were trashing a PhD epi person who was interviewing for a job. I won't go into details, but the upshot of the conversation was: How can she *possibly* do good research if she doesn't have an MD? Afterall, going to medical school is the only way one can *truly grasp* the clinical significance of the research you're doing. People with *only* a PhD in epi just aren't qualified to hold faculty jobs doing epidemiological research. Well, not as qualified as *we* will be, anyway.

I pointed out that there were plenty of doctors out there doing crappy epi research because they didn't know anything about how to design a study, despite their high level of clinical knowledge.

Then I got, "Well you really should have to do both (like we are doing), getting an MD AND a master's degree."

Well, fine. But if they think that the master's program they're enrolled in will make them experts in research without years of experience on top of that.

*shakes head*

Such a pet peeve of mine when doctors think that their MD makes them experts in everything. And that they think that other people can't possibly be better than they are at anything. These types of conversations epitomize what I find distasteful about many of them.

It just makes me so angry.

New Jersey

When Luca and I bought our house, we decided that we were too cheap to get cable. It's freaking EXPENSIVE! (Comcast SUX!) Well whatever. Most of the programming is of dubious value anyway. I mean come on. Rock of Love Bus?

We felt that we'd had our fill with the "free" cable that we got at our old apartment.

And plus! We have Netflix. Who needs cable anyway.

*****

The side effect of this is now we only have local channels (plus Universal Sports -- the most awesome channel ever).

And the side effect of THAT is that we get to see all of the political ads that come out right around election time.

The ones that were the most ubiquitous this year were the Jon Corzine/Chris Christie ads for the position of governor of New Jersey. Corzine was (I can say that now) the incumbent, but supposedly was very unpopular. I guess his constituents held him responsible for the economy?

Anyway, the race between these two gents was frighteningly close. Then suddenly, about two months ago, we started seeing ads basically insinuating that Chris Christie was lazy and slothful -- and would therefore make a bad governor -- because he is obese. They showed footage of him rolling out of an SUV, flab-a-jigglin, then lumbering by the cameras with this voice-over saying essentially that. I found these ads incredibly offensive.

Other Corzine ads talked about how Christie was going to kill your mother by denying her mammogram coverage.

Or, "Chris Christie threw his WEIGHT AROUND..."

By contrast the Christie ads -- at least the ones I saw -- usually focused on what a bad job Corzine had done as the incumbent.

I gotta say, the negative ads made me feel bad for the guy. Particularly the ones that insinuated that he was incompetent because he was obese. I think this was the opposite of the intentions the Corzine ad campaign had.

And apparently I am not the only one who felt this way, as Chris Christie actually won yesterday. By the thinnest of margins.



PS -- This post isn't about who I voted for. I don't live in NJ. So please don't yell at me in the comments. Also, if you think you are going to persuade me to dislike all Republican candidates because they are.... Republican.... by posting inflammatory comments, please think again. I vote for the candidate, not the party.

Terror

In most of the MD-PhD programs that I am aware of, the standard curriculum involves the completion of 2 years of med school followed by the PhD, followed by 2 more years of med school.

For my MD-PhD program, I was permitted to finish most of medical school before starting my PhD. This is because Epi is considered more inherently clinical than most other fields, and it was considered important that I knew as much clinical stuff as I could before I started the PhD.

Frankly, this extra time in the clinics has been invaluable to me. I am sure that I wouldn't have figured out that I liked critical care had I only had the first 6 months of the clinical rotations behind me. I might have done something idiotic like cancer research, which as it turns out I cannot stand clinically. Plus, I actually feel like I know something.

And IMPORTANTLY I never have to be a core clerkship student again. Praise the lord.

Of course doing the program this way strikes terror into the hearts of the administrators of my program because I COULD DROP OUT. I.e. I'd have only 1 year of med school to pay for rather than two at the end. Thus less incentive to finish the PhD.

As if having to be a full time doctor were not incentive enough to make me want to finish my PhD. Come on now, people.

I received a LOT of pressure during my first two years to conform to the program that everyone else was doing. And in retrospect, I'm really glad I didn't succumb. I am a lot better off this way.

Though recently I heard that MD-PhD students were no longer "allowed" to do the program "my way." I wondered whether that were really true. Whether even Epi people have to do this program the traditional way -- without adequate exposure to clinical medicine.

Perhaps I struck too much terror into the hearts of my department administrators with my doubly non-trad pathway?

Oh well. Too bad for everyone else.

A pair of misanthropes, we are

We were discussing QALYs in Econ class a few weeks back. For the uninitiated, QALYs are a way that health economists value the benefits from interventions. They use them partly because it makes some people feel all icky inside to place dirty things like monetary value on precious things like human lives.

We were talking about the kinds of things that would produce a decrement in quality of life. How there were many many life states that people valued as worse than death (though somehow states better than perfect health never came up -- is there such a thing?). How one study found that people who wear glasses have a decrement in quality of life equivalent to 0.05 QALYs. That's half a year, kids.

Anyway, I objected.

I said, but I LIKE the fact that I can go out without my glasses sometimes, because I derive utility from not being able to identify certain people from across the street.

Hee.

The professor said that these QALYs were derived from population means, and just because I liked being a curmudgeon didn't mean that everyone else did. We all laughed.

Hey! A curmudgeon! I like that!

This explains so much, really. Personally, I prefer to think of it as a healthy distrust of people I don't know well, and desire to keep them at arms distance. Cultivated by years of experience and wisdom. Obviously.

I came home and discussed it with Luca and we agreed the term was apt. A pair of misanthropes, that's what we are.

We are perfect for each other.

Get up and play an hour every day

There's a public service commercial that's been airing for the past few months whose goal is to get more children off the couch and exercising.

It features several prominent sports stars, and tells children to, "Get up and play an hour every day," and shows images of children playing with adults outside in a highly controlled environment, doing things like playing hopscotch or jumping around in a potato sack.

Why I don't like this ad:

It makes exercise seem like work.

Kind of like eating your vegetables.

Also, the "play" they show children partaking in doesn't look fun at all. Whatever happened to running around outside screaming your head off? Or hanging upside down on a jungle gym? Climbing trees? Tag?

In my opinion, children shouldn't be "exercising" at all in the regimented way that the ad implies. An hour every day? Kids should just be playing. Simple, unstructured play for however long they can. What ever happened to that?

The people who wrote this ad have framed exercise as something that you should do for good health rather than as something that is fun and completely awesome to do. To me, the ads send the wrong message about exercise, and will likely in the long run result in kids who are even less active than before.

So sad when well meaning health promotion campaigns are designed by morons.

Italian word of the day

Pelosa = hairy

Yes everybody. That means N ancy P elosi's name means "Hairy Nancy."

Hee.

Behavior Change

Yesterday we had an excellent lecture on behavioral interventions in our measurement class, specifically focusing on the integrated model of behavior change. I think I may have been the only person in the class who thought so, though.

It turns out that intention to do a particular behavior is the best predictor of whether a person will do it. Intention predicts behavior better than demographics, personality, or culture. Other things like skills or abilities and environmental constraints are also pretty important.

This is not rocket science really. If you intend to do something, you are more likely to do it than if you do not intend to do something regardless of your culture. Regardless of your personality.

So, if you find that people are not doing a behavior, first you measure a) their intention to do it, b) their skills and abilities to do it, and c) any environmental constraints.

Then, if you find that the main reason people do not do a behavior is that they do not intend to do it, you measure things that effect intentions. Like attitudes, norms, and self efficacy.

The doctors in the class got really hung up on this. "What about knowledge?" they wanted to know. "None of this works if patients don't KNOW to do the behavior."

Which explains why 90% of intervention studies doctors do involve teaching patients about disease risk factors.

"Did you know that cervical cancer is caused by HPV?"

"Did you know that smoking causes lung cancer?"

"Did you know that your baby is less likely to die from SIDS if you put them to sleep on their back?"

The problem is, education interventions do nothing to address the other factors that go into forming intention.

For instance, if you don't think YOU PERSONALLY are at risk for cervical cancer, then it won't matter that you know that HPV causes cervical cancer, and you probably won't get the vaccine.

Or if all your friends and family co-sleep with their babies, and you don't feel that you are expected to put your baby to sleep face up, then you might be less likely to do that in your own home.

Or if you feel that you would be unable to quit smoking even if you tried, then you will be unlikely to try.

The thing is, it's not that knowledge is completely UNimportant. It's that it's only a small -- VERY small -- piece of the puzzle, that maybe influences norms or attitudes, but that is less directly tied itself with intention. This means that in order to change behavior, you have to address all of these other issues besides just knowledge.

The talk kind of made me want to do an intervention study. The lecturer made it sound really interesting and cool. I had often shied away from these types of studies in the past because I've often found the people who run them to be kind of..... dogmatic..... and not especially open to discussing competing reasons why patient don't do what they say. I.e. They were not the kinds of people *I'd* want to change *my* behavior for.

But most of them were physicians rather than behaviorists. And in my experience, physicians are often the most likely to wantonly turn a blind eye to the real reasons patients don't comply (and then if you're lucky they'll label the patient difficult to boot!). So maybe that explains some of my issues in the past.

Mouse

We had a furry visitor last week, and finally caught it yesterday in one of the new traps. The snap traps never seem to spring, and we kept finding them poised for action with the bait delicately removed each morning.

How very annoying that was.

This little fellow had decided to make a home in our cupboard on our pasta shelf. He had chewed holes in most of the bags and there was pasta littered all over the bottom of the cupboard. Also shit. There was matted hair in the back by the wall where he'd started to make a nest.

Also there was shit on the other shelves and around the sink too, and tiny pieces of pink sponge littered the counter top.

Believe it or not, I think most of the damage happened Friday night. Mousy-poo had a party, so it seems.

Yesterday Luca spent most of the day cleaning out the cabinets, and we bought some plastic boxes to keep out newly purchased dry pasta in. Today he is leaving work earlier to repaint the shelves. I told him that there had never been an outbreak of Sin Nombre in Philadelphia, even with our ever burgeoning mouse population, and that it was probably overkill.

I was unsuccessful in making him feel better. He will therefore be re-virginizing the cabinets this afternoon.

Part Italian, part virologist, part OCD equals an immaculate house with freshly painted cabinets. One wonders why I complain.

At the pool today

Luca and I went swimming with a local Master's team this morning. Afterwards I had the pleasure of conversing with some of my lane mates. One in particular was especially charming.

Her: Ugh! Now I have to take the train back to the city! What a pain.
Me: Oh you don't have a car? That sound like it must be a pain to get out here.
Her: It is. That's why I swim at [your institution's pool] during the week.
Me: Really? You swim at [my institution]? What time?
Her: At 6.
Me: Do you swim with fast CCU nurse?
Her: Yes. You should come swim with us.
Me: Thanks! But you're a bit too fast for me. Also, you swim at 6AM. I am enjoying my brief respite from having to wake up at 5. Maybe I will get over it, but it looks somewhat doubtful. What do you do at [my institution]?
Her: *I* am a *PHYSICIAN SCIENTIST* (said really slowly and with emphasis). That means I have BOTH an MD AND a PhD.
Me: How interesting! Are you in a lab now?
Her: Yes, I am in basic science person's lab for a POST-DOCTORAL FELLOWSHIP.
Me: I see. Did you do a residency also?
Her: Yes, I did BOTH a medicine and pediatrics residency. It's called MED-PEDS.
Me: Hm. So are you planning on practicing and running a lab?
Her: Yes. I am entering the job market now.

It occurred to me that I could make this easier on her by telling her that I too am a physician scientist, but I was really enjoying listening to her try to explain her job to me as though I were a lay person. Hee hee.

I suppose she could have asked me too, but that's probably expecting a lot from an MD-PhD. We're a special lot. :-)

H1N1

The children's hospital affiliated with my med school had 400 ED patients in one day last week, twice the usual almost all attributable to flu, and 1/4th of them were admitted. That's 100 admissions in ONE DAY.

They have several children who had no previous health problems in the PICU on ECMO. They've had to activate extra teams to take care of the extra patients.

They're expecting the surge of patients at the adult hospital in about 2 weeks or so.

I got my H1N1 shot Thursday. Are you getting yours?

How to choose your specialty

One of the giant dilemmas in my life is what specialty to choose when I return to the clinics 4 years from now. I know, it seems like a long way off to be worrying about it. But since it's such an important decision, I find it next to impossible NOT to think about.

Part of the problem is that as medical students, everything is novel, and you can't tell if something is interesting because it is new, or because it is awesome. Also you don't really get to do much, so when you DO get to do something, you may be so excited about it that it SEEMS awesome, even though if it were your job it would suck.

I guess what I'm saying is.... rotations don't necessarily give you a precise flavor of what it would be like to do a particular specialty, and med students basically have to decide what to do with their lives based on lousy information.

For instance, on my heme-onc elective I spent about 70% of my time shadowing one of the heme-onc docs. *Sometimes* he'd let me see patients on my own and present them, but only the really easy patients with nothing actually wrong with them. A different attending let me see his new patients first, which was AWESOME, but I only worked with him a few times, and he only had a few new patients.

But the problem is this: I HATE shadowing. Can you imaging doing this from 8AM-5PM 5 days a week for a month? It was horrible. We did have a few really interesting inpatients (TTP! Diagnosed by me! She died.) so I spent as much time in the hospital as I could seeing them and attending conferences.

So the upshot is, even if if heme-onc had been for me, I think it would have been next to impossible to tell just because I hate shadowing so much.

Then there's the flip side: I tend to LIKE rotations when I am busy. Take trauma surgery, for instance. On this service, we had an actual JOB: we got to do the primary survey, which was a lot of fun for me. Then, after the initial diagnoses had been made the fellows would all leave and we'd get to stitch people up at our leisure under the supervision of the nurses and residents. Or we got to go to the OR if the case was a penetrating trauma. It was busy! I got to do stuff! And I had fun!

But do I want to be a trauma surgeon? Mmmmmm..... I don't think so. See, that would involve 7-10 year of post-med school training and a general surgery residency. Also, these people go to war and save dying soldiers, risking their OWN lives. While noble? Not so much my cup of tea. Also? This kind of doctor, while awesome and badass? Not so cerebral. I need a specialty where I have to think more.

Similarly, I've received the advice in the past that I should find someone who talks to patients in a way I admire, and then go into that. But that would be neurosurgery for me. Oh, ok there was more than one attending who had a manner I'd like to emulate (but there weren't THAT many....). And I can tell you that while I loved my neurosurgery rotation, you have to be insane to decide to do that with your life. And not just because I'm a woman. Those guys are CRAZY.

****

So how does one choose?

I wanted to share some advice I got from one of the MSCE students the other day. It seemed really wise and helpful. This with the caveat that I'm still nowhere near deciding. But it did give me food for thought.

He told me to pick a specialty that I enjoyed READING about. Because you will have to immerse yourself in it so much that you had better like reading about it, or it will make you miserable.

So I started thinking about things that I liked reading about and I came up with this list:
Neurology
Infectious Disease
Pulmonary (maybe)
Head and neck anatomy
Immunology
Toxicology (maybe)
All those genetic syndromes we learned about in Peds (though I don't enjoy taking care of this population)
Vasculitis

And things that put me to sleep:
Cancer staging
Chemotherapy
Pathology (all)
Cardiac Physiology (though I do enjoy reading EKGs and the pharmacology)
Ortho
Screening protocols
Reproductive system / Pregnancy (I tried really hard to like this. Really I did.)
Milestones/development
Endocrine
Reading about how to do any surgery. Ever.
Anatomy

Well anyway, it was food for thought. I thought it was a useful exercise. Maybe next I'll come up with a list of diagnoses my patients had that turned out to be interesting to me.

Anybody else want to share their list?

FOCUS

Last night I went to a seminar that is held for woman residents and fellows in the hospital. The seminar is designed to help build a sense of community among female physicians at the hospital, and to give woman physicians information we need, but somehow don't seem to get.

This was the first session the woman MD-PhDs in my program were invited to.

It was amazing. We got to listen to three highly accomplished women -- with families and everything -- talk about mentorship. How to find a mentor, the importance of having lots of them.... different kinds of mentoring relationships.... and how to be a good mentee. People asked questions about their particular situations, some of which were very difficult politically.

It was a fantastic conversation.

Also, being a good mentee is really hard work. But I knew that already.

One of the best parts about the meeting is that every time the conversation started to go to women, babies, or motherhood, the speakers would quickly address the issue and then move on to something else. I.e. it didn't become the focus of the meeting. There was no man bashing, and acknowledgment was paid to the fact that there are plenty of men who contribute a lot to family life who might have suggestions to offer about how to make things work better at home.

Best quote of the night: "If you've found someone you want to have a baby with? Just do it. FORGET about the rest of the world. Who cares about them."

It was the first sensible advice I've heard on the subject in a while.

I really did feel a sense of community with the other women there. It was kind of amazing, and I hope they invite us back sometime.

Benevolent Pimping

Ella had a post a few days back about being pimped as a medical student. I can't speak to what it's like at her med school, but at mine it wasn't nearly as awful as it sounded at her's.

Maybe I'm not normal though. I remember getting a question wrong about what muscles were innervated by a particular nerve on my neuro externship. I got 75% of them, but then missed the last one. I guess the typical med student would have slinked away in shame, or stood there in embarrassed silence.

Not me.

I asked the attending for another question.

I got that one right.

But I do have to admit that all this happened AFTER I stopped caring about whether I offended people during my elective rotations. It's amazing how much that helped my psychological well being in med school. I'd highly recommend it.

After that happened, I started to enjoy being pimped.* I think that's because being pimped constituted attention, and even if I didn't know the answer, it was better than being ignored all day long.

But like I said, I'm not normal. And plus, most of the attendings at my med school weren't jerks. Nobody expected us to know much, and if you didn't know something, the worst thing that would happen was that you'd have to do a presentation on it the next day. There were exceptions, but mostly it was ok.

The coolest pimping experience I ever had was by a neurosurgeon in the OR. I had been warned beforehand that the answer to all his questions was "Cushing*" so I felt prepared.

But then he asked me: Who invented latex gloves? Was it for money or sex?

Allow me to satisfy your burning curiosity. The answer is William Stewart Halsted. For sex.

So apparently, Halsted had a thing for one of his OR nurses. But her hands were becoming red and chafed from all the hand washing she had to do in order to assist him. Eventually things got so bad that she told Dr. Halsted that she was returning home to Ohio or some such because she just couldn't take the hand discomfort any longer. So, in order to keep her around, Dr. Halsted commissioned someone at Goodyear Tire Company to invent a pair of gloves so thin that they would not interfere with sensitivity while operating.

Thus, the nurse was able to continue working in Halsted's OR, and in fact later became his wife.

So if anyone ever asks you that, now you'll know!

I know I'll never forget. That's the thing about pimping, even the useless facts stick with you afterwards.



*The father of modern neurosurgery.
*So not looking forward to it on my return to the clinics 4 years from now, though!

Bubble Boy

Now I know everyone is sick of hearing about this, but I wanted to bring up one thing.

I stumbled across a string of comments about what people thought was an appropriate punishment for the parents of the bubble boy. A common theme was that we should deport the Asian-American Mom back to Japan. Some people also suggested deporting her children with her.

Excuse me?

I guess I was just really surprised that people would suggest this obviously racist sentiment non-anonymously on an internet forum. Maybe I live under a rock, though.

Anyway, I decided to ask my husband if people ever said things like this to him, being that he's Italian and all, and obviously wasn't born here.

Apparently they have. Not often, but still.

During one example, he expressed disapproval of a Bush administration policy. He was told (angrily) by a lab mate that if he didn't like it, he should just "go back to Italy."

????Huh????

So I guess even PhDs can be ignoramuses.

Apparently in the eyes of some people, if you move to a new country -- even the US apparently, you give up your right to express your opinion, in particular if it differs from the opinion that other people have.

I just don't even know what to say.

Vindication

Lot's of people tell me I should stop complaining that I will be old when I finally become an attending. That it will be weird to be the 37/38 year old intern. They then give me examples of how *they* are old. Like yesterday one of the fellows told me that it was weird for him to work as a fellow at age 36 with attendings who are 30, and since he did it, I should realize it's not such a big deal.

Hi -- Fellow does not equal intern. So not the same thing!

But for now at least. The bizzaro hospital hierarchy that sucks sucks SUCKS seems to have dissolved away.

In fact one thing that is completely awesome about my program lately is that the attendings(!) that mentor me have started taking interest in my thoughts(!). As if whatever those could be could actually matter(!).

You read that right. I've been having ACTUAL THOUGHTS lately. I know! It's been forever! And not only that, people seem to care!

I could totally get used to this.

Except as my program director pointed out to me last night -- that's just going to make it even weirder when I go back to being a med student 3-4 years from now. :-P

Oh well, at least someone gets where I'm coming from.

Anyway, I say this because at last I did hear a story that resonated with me. One of my MD PhD classmates was telling me about her mom. Her mom had become a doctor in the 70s, before you had to do more than 1 year of internship to practice. But! She'd decided she wanted to be an Emergency Room doctor instead.

Previously, if you had been an internist of any kind, you could be grandfathered into being able to practice in the ED as well. Alas, my classmate's mom had gone through after that date, and she ended up having to repeat residency at age 45. Including intern year.

That must have been an interesting experience for her. It was interesting enough that her daughter - who was 10 at the time - thought to tell me about it.

So anyway, if you hate your specialty and you're 40+, it's not too late to go back again!

And also, old is relative.

Sometimes I wish they would graduate already, and go away

A few weeks I ran into one of my classmates after going to the pool. I'd studied for 4 hours in the morning, and then decided to give myself a break before heading in to work on my biostats.

As I'm standing there in the warm afternoon sun, feeling all loose and happy, muscles spent under my t-shirt:

"OMDG! Hi!"

It was the guy from my class (well one of them, anyway) who spread the rumor that I was just using the MD-PhD program to get my tuition paid for, and that I was planning on dropping out after finishing my third year of med school. Gosh what a horrible person I was, stealing money from the NIH and [myschool] and all just to get free tuition.

I turned and looked. "Oh. Hi." I said.

"How's the PhD?" he asked in this grandiose tone of voice. I wanted to kick him in the balls.

"It's fine," I said. And then I turned and walked across the street.

Sometimes I wish they would all just graduate and go away so I wouldn't have to see them for a while. At least a few of them. My old med school classmates, that is.

Cringeworthy Epi style

An article in the NYT health section this morning was on Hawaii's law mandating that employers provide health insurance to all employees. Also, how awesome the law is, and how there is no downside.

I love the NYT.

Anyway, I thought the following quote was illustrative of a few Epi principles that the public often gets wrong.

In one example, Hawaii has the nation’s highest incidence of breast cancer but the lowest death rate from the disease.

One first reads this sentence with the brain not plugged in and thinks, "How fantastic! Hawaii health care is saving lives! Our state should mandate that employers provide health insurance too!" Not so fast. What else could be going on here?

1) Maybe the health plan is saving lives. Detecting more cancers at an early treatable stage.

2) Maybe they are detecting tumors that are very slow growing earlier, and having no effect on them with treatment. Except because they are detecting the tumor earlier, it looks like women are surviving longer after detection. This is an example of lead time bias.

3) Maybe the aggressive screening is finding tumors that would never have killed the patient had they not been detected at all. The patient undergoes treatment and doesn't die of breast cancer. Everyone assumes that it's because of the treatment, but in reality the tumor would never have killed the patient anyway. This is an example of selection bias.

4) Maybe the aggressive screening is identifying tumors that are less aggressive. Less aggressive tumors spend more time in the slow-growing phase and are thus more likely to be detected by screening than more aggressive tumors that spend less time in a slow-growing phase. Thus while it may look like screening is saving more patients lives, really only the less aggressive tumors are being detected which might not have killed the patient anyway. This is an example of length time bias.

The latter three alternatives are supported by the quote itself which states that Hawaii has a higher incidence of breast cancer AND a lower death rate.

And why is this bad? Potential waste of money issue aside, if you don't have a tumor in your breast that is going to harm you, do you want treatment for it? Does that sound like fun to you?

Dear NYT, the most of the public is not trained to think through these issues on their own, please don't do it a disservice by providing misleading information. Be a responsible publication!

Yeah. Like that's ever going to happen.

:-P

On mindfulness

There's a Pauline Chen article linked to the toilet paper blog about meditation, mindfulness, and being in the zone, and how doctors who can't manage to do this -- or at least appear that way as they answer 20 pages simultaneously -- are killing their patients. How people who remain relaxed at all times are better doctors.

I am imagining mandatory meditation sessions before rounds, and repercussions for those who appear harried when they get their 20th page in 5 minutes. Obviously we should all be completely relaxed and in "the zone" at all times. Or at least appear that way like she does. What's wrong with us? We all should be just like her.

"You don't look RELAXED," someone would say, "How can you POSSIBLY connect with your patients in a meaningful way. You are doing your patients a disservice."

How indeed.

Heads would shake, and notes would be taken on your failure to maintain composure at every possible moment. In your review, it would be written, "Not zen enough."

You know it's true in a way. I do a better job when I feel relaxed or in the zone. However I don't equate my difficulty in doing that while on the wards with professional inadequacy. You try staying relaxed under those conditions sometimes. Seriously. Even if meditation is your thing, good luck finding time to do it when your pager is on fire. Nevermind when Pauline Chen herself is staring at you cluck cluck clucking her disapproval.

And then there is this supposition that everybody should meditate in order to relax. You know what I find relaxing? Swimming, spending time with my husband, eating a leisurely meal, reading something FOR FUN. And working with data. Talking about ideas. Laughing. Being as far away as possible from people like Pauline Chen. You know, things that don't happen much when you're in the hospital.

She also advocated bitch sessions round table discussions in which doctors could air their frustrations with one another. I am just imagining detailed notes being kept about these sessions regarding who the malcontents are, to be used against participants later, just like what happens in every other work environment.

And I'm sure it would be a requirement for "frustrations" to be expressed in a way that was zen also. Actual DISPLAYS of frustration? No, that would be unprofessional.

One thing I will say: The best teams I have worked on have been those with a sense of purpose and camaraderie. Where it didn't feel as though my boss were taking detailed notes on everybody's behavior, and was focused instead on getting the job done. Where you feel like your boss has your back. Where you don't have to constantly censor yourself.

Perhaps this is why I hate Pauline Chen so much. She thinks a certain appearance (her's) equals substance when if fact that may not be the case at all. And the person who best achieves that appearance wins.

Paper

I remember the days when churning out a 10 page paper took forever. When I would agonize about how I would possibly be able to fill that amount of space. When I couldn't think of anything intelligent to say.

Those days are gone now. 10 pages comes out in the space of, oh a couple hours. Like I was vomiting onto the page. Not like it's any good the first time, but then, that's what revisions are for.

Also, I can type really fast now. Really REALLY fast. I am wondering when that happened, and am thinking that it probably has something to do with my periodic hand pain. It's funny, sometimes I'll see a doctor in clinic, usually a man over 50, hunting and pecking away at the keyboard. It amazes me that some people are that UN-adept at using computers.

And then I imagine how retarded I must look to the next generation of technology users. I've never even sent an instant message!
:-P

I turn in this fing paper in less than an hour. RIP dear paper. You are dead to me now.

Vampires

As a side note, Luca and I started watching "Let the right one in" last night, which has been really good. It was a book first, and I was wondering if anyone had read it. It was supposedly very popular in Sweden. Here is the Netflix description:

Twelve-year-old Oskar (Kåre Hedebrant), the constant target of bullies, spends his time plotting revenge and collecting news items about the grisly murders plaguing his town. But things change when he meets a new girl named Eli (Lina Leandersson), a misfit vampire who steals his heart. As a serial killer continues to prey on teen boys in their small Swedish village, Eli helps Oskar find the courage to stand up to his tormenters.

I've never been a huge fan of vampire movies or anything, but this one has been excellent so far.

Hopefully I will finish my paper before 9 tonight and we'll be able to finish it!

Paper

I have a 10 page paper due tomorrow. You know what? This thing has been sucking the life out of me for the past week. It's a total time sink.

I can't wait to turn it in tomorrow. CAN'T WAIT. Then I won't have to think about it EVER AGAIN.

The topic is only marginally germane to my area of interest, and I feel like, ALL RIGHT ALREADY, I GET IT. Cost-effectiveness analysis is fraught with error. And we still use it to make policy. Well sort of, anyway.

Can we move on now? Do I really have to write a paper about it?

And then there is all the busy-work reading that we are assigned to for class. Like the five papers we have to read in addition to the text, which we *supposedly* are going to discuss in class. Except half the time the prof never gets to them, or spends about 3 minutes on each paper. So explain to me why I need to go over them in detail in advance since they obviously aren't really that important to him?

So I've started skimming those. Thank goodness. Because before they were taking 45 minutes apiece.

It's like that for 3 out of 4 of my classes. Busy work busy work busy work. I don't have time to do anything for my actual thesis project. It's very frustrating.

Ok, I guess I'll go get this damn paper over with.

:-P

To de-friend or not

I am a self proclaimed facebook whore. I have a ton of "friends."

It's interesting though. Sometimes I will look at my profile and see that the number of friends has mysteriously gone down. As in people have de-friended me.

Gasp!

Not that I can blame them. Reading non-stop news feed from people I don't care about can get really boring really quickly. Especially when they post constantly about NOTHING.

What I usually do in these cases is block their news feed. And lo! I end up with much shorter and more interesting updates from people I actually care about.

But occasionally I really feel like defriending certain individuals. For instance, there are a number of people I friended solely to find out what they had done with their lives so far, who now? I really could care less about. And frankly, their existence annoys me.

On the other hand, doesn't it defeat the purpose of social networking applications to intentionally decrease your circle of acquaintances? Unless facebook's true purpose is to make us act perpetual junior high schoolers rather than a useful networking tool. Yes, making us all relive the agony that was adolescence probably is it's true purpose, isn't it?

So dear readers: What is your defriending policy?

What's in a name

Warning: If you don't know anything about Italy, you will not understand the humor in this.

Today at swimming, I was sitting in the gutter after destroying myself with a particularly grueling set. A man swam up to the edge.

"What's your husband's name again? Bruno? Rocco?" he inquired.

I gave him a funny look.

"You know, the ITALIAN," he said.

"Luca," I answered. I don't think he could hear me above all the splashing anyway.

I pondered whether I should ask him if his name was Billy Bob, but decided against it. I knew he wouldn't get it.

In retrospect I should I told him my husband's name was Sal.

The look on my husband's face when the guy called him that would have been PRICELESS.

5%

Last night I went to a baby shower of a woman who is in my program. I didn't know her that well. It was mainly to show solidarity. But it ended up being fun! And I met a number of women in the classes ahead of me. I was glad I went.

One of the things we talked about was the fact that statistically, only 5% of the women MD-PhDs in our class will end up with a tenured faculty position. This is compared to 35% of the men. Not great numbers on either side..... but 5%????? Kind of makes you wonder why the hell anyone does this at all with such shitty odds!

We also talked about how every single talk we go to about being a woman physician is about work-life balance. Why can't it be about something else? Is there something else? Is there anything else about being a woman in this profession that makes it different for us than for men? If not, why are we having these talks? For solidarity?

Maybe we could talk about how everyone tells us we will wreck our careers if we have a baby. At very least, "It will be hard." Well thank you, no shit. Is anyone out there telling men that? If not, well then maybe THAT'S a problem. How about how the word "feminist" has become synonymous with ugly man hater who likes to complain a lot. And how "assertive and driven" get lumped in as other negative attributes. How we're not supposed to talk about these things.

How people tell us that we just need to accept that things are harder for us. Just accept that it's likely that we will fail. How, if we want a family and a career then that is called, "Having it all^TM," and we should all know that it's ok! If we can't do it. Because, "Having it all^TM," is hard.*

Kind of like Math is hard. Therefore it's ok if you're not good at it. And, really? Why bother trying if you're bound to fail anyway.

Grrrr.....

But I digress.

We also talked about solidarity. How women compete with one another. I know I do it (I also compete with men). I saw an email forward to nominate some woman for this award and I felt this knot. Like, "I WANT AN AWARD. Why should this other woman win something?" I know I'm not the only one this happens to.

And then I voted for her anyway. I beat back the green eyed monster, and I won.

It's funny though, I feel like sometimes we're not encouraged to say positive things about people. I remember on my sub-i I found myself in a conversation with my resident and an attending who was writing a recommendation for a female classmate. And you know? I could have remained silent. Even more sinister, I could have subtly sabotaged it. (Don't ask me how, my political skills aren't that adept.)

I didn't.

I said, "X is such a hard worker! And so smart. Did you know about the xyz achievements she has had since she has been here? I don't think I could do all that. She is intense, but really really good."

(As a side note, why did I have to add a qualifier after saying she is intense? Isn't being intense a good thing? I know that when I hear that people have said it about me, it doesn't feel like a compliment. Anyway.)

The attending sneered, "What are you, her personal cheerleader?"

I thought it was kind of unprofessional, and later he apologized. But it speaks to the fact that people just don't say good things about each other very often. Particularly not med students. Maybe even more particularly not female med students.

I don't know. It's messed up. We ladies need to stick together. Otherwise what's the point of any of this if only 5% of us make it in the end.


*In fact my own mentor -- who is attempting to start is OWN career as a physician researcher right now himself AND has a baby at home -- told me that "it would be hard" to do what I'm planning to do. It's not like it isn't true, but I wondered whether if I were a man I would have gotten the same comment. He's doing it after all. It's not like it has been impossible for him.

Habits

A few weeks ago I was talking to a friend of mine back in Chicago who just completed her PhD. She was telling me how hard she worked during her PhD and how long her days were.

"12-14 hours per day during the week," she told me.

"Uh huh, " I said. I didn't want to tell her that I thought she was full of it.

You see, Med School has made me MUCH more hard core about how I count my study time. You know how most people count the time from when they start to when they stop working? I don't. I don't count checking my email. I don't count eating a snack or going to pee. I don't count the walk to school or having a chat with a friend or colleague. I don't count anything other than the pure unadulterated time I spend with my nose in a book.

When studying for my Step 1 I remember feeling especially proud of my productivity on the days when I would get 7-8 hours of pure study time in. And they probably were very productive days. I really don't do that very much anymore, between meetings and class. It's tough to concentrate for that long day after day. And besides, the reading material is different. There is NO WAY I could read a biostats or econ text for 8 hours in a day. It's just way too dry. And you have to really have your brain ON to do it.

Other problems med school created? I don't know how to study anymore. I mean, I am a champion -- CHAMPION -- memorizer. But this thinking thing? Where you have to process information? I am soooooo rusty!

And what about the fact that if I don't have some immediate deadline or stress about something, or a test, I can't seem to make myself do the work? Hey med school! You, with your constant tests and high stress level! This is YOUR fault. You ruined me for independent learning.

And weekends? I find it really interesting that the other PhDs in my department have no qualms about going out and having lives in the evenings or on the weekends. Me? Constant guilt. I could no more take a full day off over the weekend without feeling guilty than..... I don't know.... study bio statistics for 14 hours straight. Thanks for that, dear Medicine and Surgery clerkship directors!

I really shouldn't complain though. Right now I feel like I am riding this wave of project momentum. It is moving fast and I feel like I can't keep up. But that's really a good thing, right? That means despite my feelings of inadequacy regarding my productivity, I am actually moving along. Maybe this means I'll actually finish in less than 5 years.

Ha! We'll have to see about that.

Hand

Luca and I went swimming at Villanova last weekend. We'd stopped going because of time constraints (read: rotations), and out-of-shapeness. For good reason. Usually the workouts are 5000 yards or more, and the swimming fast.

So we went. And I actually received coaching! Which was very helpful. It had to do with how I was scooping (or not scooping) the water with my hands during breaststroke. And then I applied the suggestion to my other strokes as well, with significant improvement noted.

A short time after I had started trying this though, I developed a cramp in my hand. A hand cramp! Lumbrical muscle? Interosseous? Who knows? I am familiar with the foot and calf cramps, even writer's cramp, but never have I had a cramp in this place in my hand. Those I can deal with. And it wouldn't go away for hours! I was a little worried that it would still be there and I wouldn't be able to take notes during my classes yesterday. Fortunately that didn't happen.

Anyway I was relieved when I went swimming today, and it didn't come back. The hand still is a little twingy though.

And I'm glad I finally have time to swim again. I have really missed it.

Yay gentrification!

Yesterday at our annual neighborhood block party I learned that until a year ago, there were squatters in the house next door to ours.

Next door as in ADJACENT TO our house.

Maybe this explains the knocks on the door we get every so often from disheveled individuals who look like they don't bathe terribly frequently. Like that guy last week who wouldn't say who he was.

We don't typically answer the door at these times.

One of these guys told us that, "He used to live," in the house next door, "Oh a year ago or so."

Hm.

Well anyway, right before we moved into our new house, the house next door was completely renovated. Hardwood floors throughout. Central air. Granite counter tops and stainless steel appliances. New (not up to code) deck in the back. A little flashy for our neighborhood, but I'll take it over squatters any day.

Yay, gentrification!

Awesome moment of the day

Luca and I were walking back from the local watering hole (we had dinner at 5:30 in order to avoid a crowd), and I heard a couple talking behind us.

"Italian?" I said to Luca.

"No. No way. German," he replied.

A few moments later we stopped to admire a Japanese Maple in front of one of the houses, and the couple passed us. Still conversing.

"E stato qui! Mi ricordo...." the woman said.

"Haha, I was right! Your ears SUCK!" I exuded, "I am AWESOME!"

I can be really mature sometimes.