Feliz navidad a todos...

Wider post area...

I recently widened the blog's main post area using this modification from The Blogger Guide. I've heard that there may be some issues with this update when viewed on a lower resolution screen. Please let me know if you're having any problems in the comment section of this post, and I will change it back. Thanks!

Scream...

Nearly a year and a half have passed since we met, but I can still remember the terrified tenor of his screams. I looked him the eyes and caught a glimpse of a once vibrant spirit, now teetering on the edge of extinguishment. He returned my gaze with the precursor of a nascent smile for a short moment before recognizing the familiar sights and smells of his surroundings. A look of horror obliterated the smile, and in a brief nanosecond his expression changed from one of mischievousness to sheer terror at what he was about to experience. His slight three-year-old body writhed violently against the iron grip of the nurse as she attempted to calm him. "Tranquilo, Yason, tranquilo. Shhhhh. Tranquilo."

At this point in my trip to Guatemala, I had been working mornings in the operating room for about two weeks. A small stroke of luck brought me to this moment. I had traveled to Guatemala intending to learn Spanish at a Guatemalan school, with the hope that I would have the opportunity to spend some time observing and possibly helping local doctors at one of the many clinics sponsored by international aid organizations. My first few days of volunteering were spent in one of these clinics, where I encountered a total of three patients in twelve hours. After making a connection with one of the local doctors, I asked for a transfer to a hospital, and found myself on the bus to a small city in the highlands the next morning at 6:00 AM. Upon arrival, the physician in charge asked where I would prefer to work. He was pleased when I chose surgery and sent me down the hallway to the surgical wing of the hospital, which consisted of two small operating suites that had clearly--even to my untrained eye--been built sometime in the late 70s. Seafoam green tile covered the walls, and the operating lights lacked the occasional bulb or two. I changed into a pair of borrowed scrubs, conversed with an anesthesiologist for a few minutes in broken Spanish, and was then asked if I knew how to scrub. My first operation was a cholecystectomy on a thirty-five year old woman--a standard operation in the land of little access to birth control and 5+ parturitions--and I never looked back. I learned how to snip suture, hold retractors, and operate the bovie as I went along, finding the work simultaneously fascinating and immensely enjoyable.

Yason was different. He was three, and, as far as I could tell, had once been the archetypal healthy young Guatemalan. I had scrubbed on a few pediatric cases in the preceding two weeks--hernias and such--but this one was bore no resemblance to the others. Severe burns covered roughly fifty percent of his body. According to the doctors, he had pulled a pot of boiling water onto himself, and had been in the hospital for the past two weeks. New skin was slowly displacing the dead tissue, but pus and scabs were forming over the burns, necessitating disinfection and debridement. This was his fourth trip for debridement since the injury, hence the writhing and screaming. I stood at the scrub sink and attempted to fortify my emotions for what I knew would be a tough case.

Fast forward a year and half. I am sitting in a lecture on child and elder abuse for a class on human behavior. A slide flashes across the screen depicting patterns of injury that indicate abuse, and the moment comes rushing back. Suddenly, I am standing in the OR, gloved and gowned, with the surgeon and a medical student. Weilding sterile brushes with plastic bristles, we scrub--back, buttocks, back of the thighs, parts of the foot, the palms of the hand. Yason whimpers despite the anesthetic, his face flinching now and then, screams and contortions numbed by unconsciousness. Rich carmine blood oozes from the burns, as if protesting our assault on the skin's healing processes. We finish after forty-five minutes of scrubbing, our white gloves stained bright red, bristles glistening. Yason whimpers more as the anesthesia begins to wear off and we apply bandages to the burns. A nurse wraps him in a blanket and spirits him off to recovery.

After Yason was gone, I stepped back from the OR table and removed my gloves and gown, finally permitted the chance to contemplate the event in which I had just participated. My eyes welled up with tears for the young boy, a few dripping onto my mask and darkening its baby blue fibers. I marveled at the seeming lack of fairness. It made me want to scream.

But now--with nearly a semester of medical school behind me--I think my reaction to the case would be changed. If I encounter something similar on the wards as a medical student, the case will hopefully have been referred long ago to child protective services. American burn care is also much more advanced than that available in Guatemala. But I would still want to scream. I hope I never lose that impulse.

(image via Wikipedia)

Please keep this person in your thoughts...

Those of you who are familiar with the medical or military blogospheres may have heard of CPT Rob Yllescas, a soldier who was severely injured in Afghanistan about a month ago. He arrived back in the United States a few days after his injury and has been receiving treatment at Walter Reed ever since. His wife keeps a blog with updates on his condition that can be found here. Earlier tonight he suffered a clot in his brain, and he is currently undergoing surgery in an attempt to save his life. Please keep him and his family in your thoughts during this unimaginably difficult time.

dr im sick. :-( rofv.

I've been spending the weekend thus far studying for an upcoming biochemistry exam, so I thought I would drag myself up from the mess of initiation factors, ribosomes, and lipoproteins in which I am immersed to update my blog. The consistently heavy workload that defines medical school tends to curtail the amount of time I have to spend writing updates. But study breaks spent pondering subjects only tangentially related to the material tend to reinvigorate the mind. Or at least that's the goal.

Anyway, this past week, a disheartening post on the NYTimes Bits blog came across my Google Reader. The gist of it is thus: a new physician-led, internet-based company--American Well--is in the process of rolling out a service that offers patients online consultation with a physician over video and chat weblink. The company's founder claims to be motivated by a desire to make the most basic element of healthcare--talking to a doctor--easily available to the numerous healthcare consumers who obtain the majority of their health-related information through online means.

At first blush, this may sound like a desirable proposition. Both the typical, and I use that word broadly, healthcare consumer and the physician who treats him or her are time-starved. The opportunity to consult over chat with a physician for ten minutes rather than set aside a minimum of an hourlong (counting trip, time spent in waiting room, etc.) block of time for a trip to the physician's office might provide a significant benefit to the patient. Instead he or she can, from the comfort of a favorite chair, sit and dicuss the most intimate of subjects with a caring and compassionate physician.

This is the point at which the premise begins to crumble for me. Aspiring doctors are introduced to the proper methods of interviewing sometime within their first year, hopefully prior to the first contact with living, breathing patients. We learn the importance of sitting on the same level as the patient, asking open ended questions, maintaining eye-contact, and proferring encouraging statements when subjects cover topics that might be hard for a patient to relate to a stranger. These techniques are taught with a single goal in mind: to communicate our willingness to listen confidentially and non-judgmentally to our patients, while remaining attuned to the salient issues of their lives.

By virtue of its basis in realtime video chat, the interaction between physician and patient offered by American Well suffers from an interruption of this attentiveness. As a student who lives far away from friends and loved ones, I use Skype nearly every day to keep in touch. Yet despite a high-speed connection, there are often technical issues that interrupt the flow of conversation. And anyone who chats via webcam knows that it is no substitute for the type of interaction available through a face to face conversation.

I can see you saying to yourself now, "you're overreacting, American Well doesn't aim to replace face to face conversation between doctor and patient. It's just a useful tool for checking in with your physician and getting some advice." To which I respond: just wait. Supplementing the doctor-patient interaction is not the American Well's aim. The founder of the company puts it best: "without reworking the budget, without going through Congress, we can bring affordable health care to people who cannot access it." This ephemeral, vapid talking point would almost make me laugh, if access to healthcare weren't such a pressing issue. American Well markets their product to physicians on the notion that it will permit them to "Increase revenue and care for patients on [their] own terms. [And] Introduce a new balance to the way [they] practice by offering [their] services online for a fee." Clearly, the number of those with access to healthcare isn't expanding.

And how, may I ask, will this bring affordable healthcare to anyone who currently lacks access? It won't. Let's offer a scenario in order to illustrate. Let's say American Well allows physicians to charge 50 dollars for a ten minute online consultation:

Ms. B, a post-menopausal 56 year old woman, works as an insurance agent. She has been having headaches off and on for the past few weeks. She doesn't think her symptoms are anything to worry about, though she would like to get them checked out just to be sure. But Ms. B doesn't have health insurance. Her headaches have been worsening over the past two days, so she decides to pay 50 dollars and see a doctor on American Well. Dr. X, prudent physician that he or she is, sees that Ms. B is overweight, is concerned that these headaches could be related to possible undiagnosed hypertension, and tells Ms. B that she needs to see a physician in person. The doctor's concern worries her, and she agrees to pay $110 dollars to see a physician in person.

Outcome A
The doctor rules out hypertension, talks to her about some lifestyle improvements, prescribes 800 mg ibuprofen, and tells her to schedule another visit if the headaches continue to worsen. Total cost of treatment rises from $110 to $160, not including the cost of medication .

Outcome B
Despite the physician's advice, Ms. B decides her headaches aren't that bad and that she can tough it out for a few more days to see if they get any worse. Little does she know, her blood pressure is sky high. She wakes up in the middle of the night three days later in a cold sweat, unable to move her right side. Her husband calls paramedics and she is rushed to the hospital, where she is diagnosed with a severe stroke. She spends a week in the hospital, her blood pressure is brought under control, and she slowly regains function in her right side. Six months of physical therapy follow. Cost of treatment: $50 + ambulance ride + stroke treatment + rehabilitation.

Outcome C
Thankfully, Ms. B isn't aware of American Well in the first place. When her headaches worsen she goes to see a primary care physician for $110. She is diagnosed with severe hypertension, the physician prescribes her a relatively inexpensive generic medication, tells her to come back in a few weeks, and has a conversation with her about lifestyle changes. On her second visit, her blood pressure is back in the normal range, she has lost a few pounds, and plans to lose a few more. Cost of treatment: $220 plus cost of medication. Stroke averted.

Outcome D
Again, Ms. B isn't aware of American Well. She pays $110 to see a doctor, who finds her to be mostly healthy, except for a few extra pounds. They have a conversation about healthy lifestyle changes, and she gets a prescription for 800 mg ibuprofen to take as needed for her headaches. Total cost of treatment: $110 not including the cost of medication.

I ask you, American Well, which outcome is better for the patient? For the American healthcare system? Is this really even a question?

(image via Wikipedia)

If you do nothing else tomorrow...

PLEASE GO VOTE!!!!!!!

Thanks for the memory...

Thursday afternoons are always the highlight of my week. My weekly schedule normally goes something like this: For about three hours every morning, my entire class (or those of us who choose to attend) sits in a large lecture hall, listening to various professors expound upon the intricacies of their chosen fields. Biochemistry is the designated (and much disliked, in my mind) topic on Tuesdays, Thursdays, and Fridays, while Mondays and Wednesdays are filled with gross anatomy. Monday and Wednesday afternoons are spent in the anatomy lab dissecting out the various structures that were covered in the morning lecture session. As an aspiring surgeon who enjoys nothing more than wielding a blunt probe and pair of small, slightly curved scissors in the battle for anatomical knowledge, I enjoy anatomy a great deal. There is nothing more remarkable than the intricate layering of the various muscles and tendons in the hand and forearm, or profound zigzagging of the brachial plexus nerves, which appear muddled when seen for the first time but gradually yield their own logic when revisited dozens more.

Occasionally, the dissections prove more frustrating than didactic, and yesterday was no exception. My lab team and I were scheduled to observe the abdominal viscera in situ, expose the vasculature of the gut, and delineate the main vessels that branch off the abdominal aorta. We are assigned to cadavers in groups of eight, with four people dissecting at any one time. For this section--thorax, abdomen, and pelvis--we work in groups of four for two hour shifts, with the second group continuing the work started by the first. I was in the second group yesterday and expected to find a colon and a small intestine with vasculature exposed upon my arrival in the lab. Instead I spent two hours sorting through the remnants of Beatrice's (her nom de guerre) bowels, which had undergone quite extensive surgical alteration. The entire colon was missing, with the end of the ileum anastomosed to the cecum, which had been sewn to the rectum (sub-total colectomy?). The previous groups had spent an entire two hours clawing their way through the mess of adhesions that was the small intestine. What was left of the superior mesenteric artery and its branches in the small intestine had been exposed, but there was still a great deal of work to do. So we jumped right in and attempted to find the inferior mesenteric artery braching from the aorta. I say attempted, because we discovered that it had been cauterized and removed in its entirety, save the superior rectal branch. Following that morass was a two hour struggle to expose the portal triad (portal vein, common bile duct, common hepatic artery). We scratched our heads for a hour or so while we revealed branches incorrectly branching off of other braches, which looked nothing like any of the variations that Netter so masterfully depicted. After some oooohhhhs and aaaaahhhs along with the anatomy professor at what we'd found, we concluded that we had another unique variation on our hands, and left the lab exhausted.

I am constantly amazed by the extent to which the body serves as a record of all life's occurrences, from the catastrophic to the imperceptibly minute. I'm not talking about the obvious here--years of smoking, major surgery, traumatic injuries, etc--but about the tiniest of tiny things. My foray into the anatomical variation of the celiac trunk and superior mesenteric artery was the product of an event that began approximately seventy-four years ago, when a few cells migrated a few micrometers in a strange direction during the embryonic stage of development. I doubt Beatrice felt any adverse effects from this event during her lifetime, and yet I, humble student, was privileged enough to discover its record almost three-quarters of a century later. Sometimes being an anatomist, even an inexperienced and occasionally bumbling one, provides the opportunity to play archaeologist for the afternoon.

But I digress. Back to my weekly schedule. Most of my Thursday afternoons are spent in the hospital playing archaeologist of a different sort, sorting through the physical and emotional events of patients' lives as my fellow students and I nurture our nascent interview skills. My group of five fellow students and I have conducted only about ten interviews so far, but we've encountered some fascinating stories. Today was no exception. We interviewed an elderly woman struggling with Parkinson's, once a healthcare provider herself. Despite what appeared to be a slight pharmacologically-induced delay in her cognitive processes, she was sharp as a tack, remembering well and maintaining her dignity and bearings while six rather green medical students peppered her with questions. I was reminded of my grandfather--a truly great man--who suffered from debilitating Parkinson's for many years before passing away about six years ago. So thank you Mrs. X, for our encounter today. Though you didn't know it, talking with you elicited the most pleasant of memories and certainly brightened my day.

Damn, I'm lucky to be doing what I'm doing.

Evolution...

Around this time every year, thousands of students, young and middle-aged, throughout the country are considering applying to medical school for admission to the fall class that will matriculate in two years. If they are fortunate enough to attend a college or post-baccalaureate program with a dedicated professional school admissions advisor, such as I did, then they are likely attending meetings on a regular basis to ensure that the important milestones in the process of selecting schools and filling out the AMCAS application are on track. Preparedness at this early stage means two things: planning to take the MCAT in the spring, and writing the first drafts of the admissions essay that will serve as cornerstone of the medical school application.

Preparing for the MCAT is mostly self-explanatory. A certain amount of science must be reviewed and, if necessary, relearned. Achieving the MCAT score that will yield the best chances of admission requires dogged persistence and rote study of the material, no more, no less. Writing a good AMCAS essay, however, is a different story, or more aptly, a consistently evolving narrative. Two years ago, when I was at this particular juncture in my medical career, I found the writing of the essay to be the most difficult task of the whole application process. Medical school applicants are a diverse bunch who find common ground in medicine. Many of us major in biology, but others take less traditional routes--English literature, history, philosophy, dance. The overwhelming majority have experience in some aspect of the medical field, ranging from biomedical research, to relief work in third world countries, to volunteer work caring for the elderly and infirm in nursing homes. And these qualifications are by no means mutually exclusive; the most visible applicants are those who defy easy categorization. A tuba-playing, HIV-researching, comparative literature and biology-majoring student who finds the apotheosis of human existence in the octogenarian whose endless font of stories she taps every Thursday afternoon when she volunteers at her local nursing home represents a typical combination of extracurricular and personal qualities seen in a medical school applicant.

Which is what makes the writing of the application essay such a taxing proposition. The golden nuggets of truth derived from years of academic and personal growth and achievement must be summarized in the cramped space of a meager 5000 or so characters. But, more essentially, these nuggets must convince their intended audience that the applicant's motivation to become a doctor grew out of a fundamental curiosity regarding the functioning of the human species within its set environment, which is really what health boils down to at its core. Which begs a single question: what leads a person down the path to becoming a doctor?

In conversations with my fellow first year classmates, I've found, unsurprisingly, that our motivations are as diverse as our backgrounds. Some are engineers who see the human body as the most intricate of machines, others find themselves enamored of the complex science that underlies the most elemental physical functions. Still more choose to enter medicine not for its scientific offerings, but for the opportunity to be part of the solution to one of the greatest humanitarian issues of our time--the unconscionable disparity that exists in our contemporary healthcare system. Personally, I have chosen to become a doctor for one primary reason--the opportunity to witness the life and health narratives of my patients.

But that certainly was not the only reason I applied to medical school, which further complicated the essay writing process. If some of my readers here are currently working on their essays and looking for some useful tips, I have one that proved very useful as I fought through numerous drafts on my way to a successful final copy. However you have arrived at your current desire to become a doctor, demonstrate how that process is one component of a consistent evolution. It might be an obvious point, but I'll say it anyway. Expect medical school to change the way you look at the world and interpret the interactions with those who surround you. Roughly six years from now, when you walk across the stage at graduation, you will be seeing the world through an entirely new set of eyes, hopefully one that allows you to better understand your fellow humans--anatomically and physiologically, yes, but also economically, socially, humanly. Let your essay show that you adequately prepared for this evolution, and understand what it entails. The medical profession requires constant adaptation and reinvention. Be prepared.