health.spot

Hippocratic Oath 2.0

Times have changed since the days of Hippocrates and so too have the things that physicians must be wary of in practicing their art. The following “Hippocratic Oath 2.0” takes count of these new pressures. It also incorporates some of my own views as to what is important to the practice of medicine and for patient health. (Special thanks to Robin Hanson.)

I swear, according to the accumulated knowledge of the allied health professions and of the economists who study this field, I will work to become the best physician that I can be to my patients. Thus…

…I vow to fully engage my medical studies, so as to have as much knowledge at my disposal as possible when it comes to the treatment of my future patients

…I vow to hone my medical Spanish so as to be a better provider for the variety of patients that frequent USC-Keck hospitals

…I vow, to the best of my abilities, to practice evidence-based medicine

…I vow to do as much as is needed to treat a patient’s pathology and no more

…I vow to be cautious in administering new therapies that do not yet have a track record

…I vow to prescribe the generic version of drugs when that is an option

…I vow to foster a collaborative environment with the other healthcare workers on my team. 

…I vow to see my patients promptly, without excessive waiting room stays

…Acknowledging its difficulty, I vow to talk to my patients about avoiding unhealthy behaviors and to encourage taking up healthy ones. I vow to stress the centrality of diet and physical activity to the patient’s health.

…I vow to keep my own body and mind in excellent condition so as to be the best practitioner of medicine I can be

…I vow to stay up to date on the medical literature, or to cease practice when my techniques grow stale

…I vow to stick to the above vows 99% of the time; yet to discard them in rare circumstances where the good of the patient requires doing so

Now, if I keep these vows, may I enjoy excellence, in my profession and in the practice of medicine, throughout my career. 

Go Trojans!

Hey Team,

Just checking in to let you know that I’ve now begun classes at USC Keck School of Medicine in sunny SoCal. I’m exceptionally excited to be beginning the journey into doctor-dom. More to come……

Z

All about Ophtho

Life update: I’m done with my postbac premed coursework and, during the year-long lay off between applications and getting into med school, I have joined the work force!

Can you imagine your vision failing? I’m not talking about being unable to read the 20/20 line on your vision chart. I mean seeing a black donut hole in the middle of your field of vision—leaving you with only peripheral vision (ARMD; left). Or conversely, losing most of your peripheral vision and thus having a “telescopic” view of the world (glaucoma).

In my current position as an ophthalmic technician at Retina Consultants, P.C, I see these sorts of problems every day. There, I assist ophthalmologists in the treatment of patients with retinal problems, including retinal detachment, posterior vitreous detachment, retinal tears, age-related macular degeneration, uveitis, and diabetic retinopathy.

My primary duty is to perform a full eye examination—a “screening”—before the doctor sees the patient. The screen begins with characterizing the patient’s chief complaint and taking their medical history. It proceeds with various tests: for visual acuity (the “E” chart); peripheral vision (using the “Humphrey Visual Analyzer” machine); eye muscle motility (“follow my finger”); pupillary reflex (does the pupil accommodate to bright light?); and intra-ocular pressure (see left).

The screen concludes with my using two different sets of drops—a sympathetic agonist (phenylephrine) and a parasympathetic antagonist (the anticholinergic Tropicamide)—to fully dilate the eyes so that the ophthalmologist can, with the aid of very bright light, peer through the giant pupillary opening thus created into the back of the eye, aka the retina.

In addition to screening duties, I also assist in procedures, including Avastin injections and laser treatments. Avastin injections and laser treatments are typically aimed at reducing overgrowth of capillaries in the back of the eye, which often leak or otherwise obscure the functioning of the retina, thus decreasing vision. Sometimes a laser treatment is able to “pin down” a retinal tear before it advances into a larger retinal tear or full-on retinal detachment.

In the near future I will also be operating two pieces of equipment that will image the back of the patient’s retina, one of them in which I will also inject the patient with fluorescein dye. When the time comes, I’m looking forward to gaining this additional clinical experience. I am already very pleased with the duties I’ve been entrusted with so far.

In my view, our most important function at Retina Consultants, P.C. is to be an early responder to any signs that the retina is starting to tear or become detached. Vision is a precious thing, and the fact that we have ways to preserve it in the face of what otherwise would be debilitating conditions is a marvel. That said, it is important to note that sometimes “the damage has been done” and there is not much more we can do other than actively monitor the situation.

Postbaccalaureate Premedical Programs

Having just completed a postbaccalaureate premedical program, I have some perspective on it that I’d like to share here:

First off, what are we talking about? Well, a postbaccalaureate premedical program is pretty much a fancy way of saying that you’re going to pay to take the premedical prerequisites for medical school and that you’re going to do so having already received your college degree. There may be some degree of structure to the program. I know for instance, that the Scripps program had a former postbac student (waiting to begin medical school) helping postbac students adjust their course schedules as well as helping them with homework, even. Postbac programs tend to have a more responsive and invested adviser.

Is it necessary to attend a postbaccalaureate program to attend medical school?

No, you can take the necessary classes at your local state Uni. Yet there are advantages to postbac programs. For instance, certain programs, like Goucher, Bryn Mawr, and Scripps, all but guarantee acceptance into med school, should you be accepted into said programs. Yet this may because the screening process is so tough: you pretty much need a 3.7+ GPA and an SAT (which correlates with MCAT score) of 1400+ to have a shot. These schools also allow you to begin medical school shortly after completion of the postbac program, without the year-long delay that other postbacs endure between submitting their applications and matriculation. A given student must maintain a high GPA (I want to say 3.6-7+ and MCAT scores 30-31-32+) in order to be “linked” in this manner.

I actually think the most important distinction isn’t between taking classes in a postbac vs. entree-style. It’s between taking courses at public vs. private schools. I highly recommend taking your coursework at a private school. The fact is, public schools have large classes and unforgiving curves. Private schools tend to be more liberal in their grading. (And this is particularly important in your science-based coursework: physics, organic chemistry, general chemistry, and biology—the courses comprising your postbac.) Given average matriculating med school GPAs in the 3.7 range this is a very important distinction indeed. The drawback to private schools, of course, is their price. Perhaps the best of both worlds would be to take coursework at a less competitive state school. Medical schools, for whatever reason, give hardly any weight to where you take your classes (though you would be wise to avoid community colleges).

So that’s some general knowledge about postbac programs. Feel free to ping me for more. Now what follows, as printed in Catalyst magazine, is my take on the American University Program in particular:

Elspeth Clark isn’t your typical premed. She has already received her degree—in linguistics from Cornell—and she’s spent the past two years in Japan teaching English. Yet the 27-year-old Clark currently finds herself taking undergraduate cell biology and biochemistry here at American University—not to mention acting as a general chemistry laboratory teaching assistant and volunteering at Children’s National Medical Center—as she works toward a career as a physician.

Though not your usual premed, Clark is far from alone on campus. Many others have recognized, after completing a humanities degree, that their true calling is medicine—or some related health field. There are currently 47 such “postbaccalaureate pre-health students” at American University, enrolled in courses such as organic chemistry and physics that are required by medical, dental, and veterinary schools across the country.

Lynne Arneson, adjunct professor of biology in American University’s College of Arts and Sciences, oversees postbaccalaureate students in her capacity as premedical programs coordinator. Describing her advising role as her “primary focus,” Arneson maintains that the life experience postbaccalaureate students have accumulated serves them well in navigating the difficult path to medical school.

Nonetheless, Arneson, who took over as premedical programs coordinator in 2009, personally provides a wealth of support services for postbaccalaureate students to help them along the way. In addition to overseeing the creation of a committee letter in support of each postbaccalaureate’s application (“it turns the applicant from a GPA and MCAT score into a living, breathing, 3-D person”), Arneson organizes health-related volunteer work; publishes a premed newsletter, the Annual Checkup; enforces application deadlines; and requires students to attend mock interviews. “We keep track of the administrative details so students can focus on their studies,” says Arneson.

“I chose the American University Postbaccalaureate Program because I wanted structure and advising as I completed my premed requirements,” says Adriana Ponce, an ’08 graduate of Loyola Marymount University, where she double-majored in art history and political science. Ponce, who appreciates the personal attention she gets from her professors at American University, also values the fact that “Dr. Arneson’s door is always open.” In fact, Arneson teaches classes only before 10 a.m. or after 5 p.m. so that she can maintain maximum availability for her advisees.
While contemplating a career as a lawyer, Ponce ultimately decided on medicine after consulting with her family. Her father, an interventional cardiologist practicing in Los Angeles, helped her to realize the joy that comes from caring for patients in their time of need. Immediately after graduating, Ponce applied to the American University Postbaccalaureate Program, where she is currently taking physics, upper division biology, and biochemistry courses. Ponce looks forward to a future career as a physician, which she views as a “vocation as opposed to a job”—a calling.

Although most postbaccalaureate students are pursuing human medicine or dentistry, there are a few who are taking courses in preparation for a career as a veterinarian. Stephanie Abrams, an environmental studies major at Skidmore College, is one of them. She was struck by the care and attention with which veterinarians worked to save the life of her dangerously ill kitten. She went on to shadow several veterinarians before deciding to pursue a veterinary career. While taking physics and biochemistry at American University, Abrams plans to volunteer at the National Zoo in Washington, D.C., next semester. Abrams, like Ponce, has a father who practices as a physician—and a mother who practices, too—but ultimately decided that caring for animals was where her passion lay.

A notable difference between postbaccalaureate programs and a typical premed path is that the former occurs on an accelerated schedule. While a premedical student takes four years to complete requirements, a postbaccalaureate student does it in one or two years. Thus Clark, Ponce, and Abrams will all be applying in fall 2010 for matriculation in their chosen health graduate school in fall 2011. “It’s a rare night that I’m not studying, grading, or reading,” says Clark as she prepares for the home stretch.

For all their hard work, Clark and company have a lot to look forward to. American University postbaccalaureate students have gone on to attend some of the most prestigious medical and pre-health professional schools in the country. A partial list of schools at which American University postbaccalaureates have been accepted in the past two years includes George Washington University School of Medicine, the University of Colorado Medical College, the University of Maryland School of Medicine, Virginia Commonwealth University School of Medicine, the University of Tennessee Health Science Center, the National Naval Medical Center, the Uniform Services University of Health Sciences, and the University of Pennsylvania School of Dentistry. For the 2009 application cycle, the American University Postbaccalaureate Program boasted an acceptance rate of 85 percent for qualified applicants, designated as those with a GPA above 3.3 and MCAT scores above 8 per section. “I think all of my students deserve to go to medical school after everything they’ve been through,” says Arneson.

http://american.edu/cas/catalyst/upload/2010-spring-catalyst-sm.pdf

The MCAT is G-Loaded; Prep Company Tests Not Representative

Yesterday I took the MCAT, and, while I’m cautiously optimistic about how it went, I have to say, I was a little surprised by the test’s format and style of questioning.

For the past few months I have taken a Kaplan MCAT prep course. The course comes with practice full-length tests meant to approximate the authentic MCAT experience.

These practice full-lengths were not like the actual MCAT. Nor were practice tests from Princeton Review, which I also sampled.

Rather, the tests most like the actual MCAT were the set of practice tests put out by the AAMC, which creates and administers the MCAT.

Prep company practice test really require you to have set to memory a great deal of equations and discrete knowledge about science. If you don’t have the equation for estimating torsional strain set to memory, you will lose points. In addition, ask anyone studying for the MCAT and they will wax on about how much discrete detail they are memorizing.

While it helps to know the equations and in-depth biology details cold for the MCAT, it is by no means required. The MCAT was primarily a reasoning test—an IQ test, in a word—that required an (IMO) relatively superficial understanding of the concepts—and the most basic equations like v=lamda*f—but asked you to use your reasoning abilities to apply said understanding to novel problems. Similarly, you didn’t need to know biology at the level of detail required by Kaplan practice tests. You didn’t need to have all the intermediates of the Kreb’s cycle memorized—but you should know that glycolysis takes place in the cytoplasm, the Kreb’s cycle in the lumen of the mitochondria, and the electron transport chain across the inner fold of the mitochondria.

They actually asked me a question about the location of the electron transport chain, although it was “cloaked” such that it took some reasoning ability and a synthesis of various concepts to understand that that was the question being asked. This style of questioning is typical of AAMC practice tests but not Kaplan ones.

Unlike Kaplan tests, equations and relationships were explained in detail in the passages, which contained many of the answers necessary for answering the questions. And there were often two different places in the passage where one could find the answer to a question, unlike prep company tests.

Unlike Kaplan, reasoning allowed you to eliminate many wrong answer choices. On questions that I knew little about (I’m not trying to say *no* knowledge is required), I was usually able to whittle down the answers to two and sometimes one.

The physical sciences section for me was very chem heavy, with little physics. This was the mathiest section by far but far less mathy then Kaplan tests. I was not asked to call upon my knowledge of equations with logarithms in them, which is good, because I can’t say I have those equations down cold at all! (I’m referring to those equations like ln RT eq something or other.) The math performed was not at all intensive.

I found the verbal section to be different than SAT verbal. The passages were fairly easy to understand. Yet the questions often did not have a clear right answer—I was often between two choices. Verbal is typically my strength and I did not have this problem with the SAT. I would typically read the passage with no problems, then hit the questions and realize I understood far less than the questions required. The passages, note, were quite long. Others have mentioned that the major way Kaplan tests are unlike the actual MCAT is the verbal section, and I found this true, though I think this critique applies to the other sections as well IMO. The one thing I would say here is that the MCAT purposefully does not put obvious right answers to their inference-based questions. They seemingly provide a 90% right option, 70% right option, and two wrong answers.

For bio, I had one o-chem passage and a few discretes. I had two genetics-based passages and a few discretes there. This is in line with a trend I had heard about at StudentDoctor of o-chem being replaced progressively by genetics. The o-chem passage was pretty basic, too, I might add, as were the o-chem discretes.

Maybe I paid less attention then, but when I took practice SATs from prep companies, they sure seemed to be like the actual SAT.

Note that I’m not saying practice tests from prep companies aren’t useful in furthering the knowledge you need for rocking the MCAT. Just saying they aren’t very representative IMO. My advice to you is to take AAMC tests 3-10—with special attention to the last 5 or so, which are the most representative—multiple times to get a feel for what the test will be like. Use test prep company practice tests to cement your knowledge but not to give you any indication of what the actual test is like or how you will do.

Spring Grades Are In—4.0 at AU; next stop, MCAT!

BIO-210-006 General Biology II 4.00 A

PHYS-210-008HUniversity Physics II 4.00 A

Taking Stock

I was born in San Diego, California in October of 1984 at Sharp Memorial Hospital, where my mother still practices as an Emergency Department physician. My mother considered herself blessed that she had ever had a child at all, given previous use of a type of birth control pill that was later found to render many childless.

My earliest memories relate to—of all things—my participation in youth sports. I was a champion sprinter in grade school, a talent I turned into a weapon on the soccer field. At the “right wing” position of the “Surf” Soccer team, I remember practicing biweekly on polo grounds, traveling to tournaments at far-away places like Las Vegas—and most of all, the feeling of zooming toward the goal with a soccer ball at my feet. My efforts on the soccer field culminated in our team being named state champions when I was ten—it was a joyous ride home to San Diego from Sacramento.

Like a typical Californian, when I wasn’t playing (or practicing) soccer, I was often outdoors: cruising around on my longboard skateboard, bodysurfing at the beach, or playing “pogs” with the other kids on my suburban block in Del Mar.

Beginning with pre-K, I had the privilege of attending a series of selective, private schools. Indeed, I have never attended a public school, for better or worse. At La Jolla Country Day School, the earliest subject I remember learning was D’Nealian, a type of print writing that one learns before cursive. I remember learning how to curl my “r’s” and “f’s” just right. I remember participating in arithmetic exercises where one arrives at a mathematical way to form “24” from four different numbers. I remember science projects in which I examined the effect of different lubricants on a train track; I remember (visiting and) building a model replica of the San Juan Capistrano Mission, a former Spanish missionary outpost in California that recruited American Indians to the Christian faith.

Sometime in middle school my interests became more intellectual. I became very much enamored of a series of detective novels, reading every single Hardy Boys book in print. I was so captivated by this series of books that, upon finishing them, I even took up Nancy Drew novels, which were designed for young female readers! A few years later I would discover my own knack for writing, and became a proficient short-story writer. One of the most important things that La Jolla Country Day did was to get all students on a computer as soon as possible. The touch-typing I learned then served me well in this endeavor. At this time, I also became interested in chess, participating in tournaments throughout the state. I continue to play chess, though only recreationally, today.

At age 13, I had my Bar Mitzvah, where I read in Hebrew from the Torah and delivered a sermon from the Haftarah. By this point I had become a fairly potent critical thinker. I distinctly remember being an atheist by the time I underwent this initiation ritual.

I went to high school at the Bishop’s School in La Jolla. I grew to be quite large—6’3”, to be exact—while there. Thus while I continued to excel on the soccer field, I also took an interest in football and tennis, serving as running back for the Knights for two years and playing varsity tennis all four years of high school. At Bishop’s, I took a rigorous course load that taught me the fundamentals of mathematics, science, Western history, and writing/composition. I put my writing chops to work in penning a column for the school newspaper, The Tower. I recall an exposé on local favorite hamburger place In-n-Out and its secret menu receiving wide readership. My continued interest in creative as writing secured me a Molly Martinek award for a short story I wrote relating a story of a young person who goes fishing for the first time and his reflections on the morality of the act. I was named a National Merit Scholar for my performance on the PSAT, and performed similarly well on the SAT. My senior year, I accepted an invitation to attend Pomona College, a liberal arts school located in Southern California.

At Pomona, my mentor was John Seery, a professor of political science, who would later serve as my advisor. I visited his office at least weekly to debate him on any number of socio-political points. I had discovered the elegance of economics by this point and was eager to compare my “rational choice” model of human behavior to his more sanguine view of human nature. Unable to convince him, I put my opinions in print, serving as assistant editor of the school newspaper, the Student Life, penning columns on everything from local campus politics to the arrival of Facebook at Pomona. (In the beginning, Facebook was rolled out school by school.) Liberated from having a prescribed curriculum, I took a wide array of courses at Pomona. I learned Mandarin Chinese up to an intermediate level. I took computer science courses. I took neurobiology courses, where I recall ablating a section of a rat’s brain called the nucleus accumbens in order to measure the effect on his movements. (An even more interesting neurobiological happening was when the girl to my left feinted as a result of the procedure.)  True to my interests in writing and the nature of human action, I majored in political science. I graduated in 3.5 years, and headed to Washington, D.C to take an internship with the Cato Institute.

The Cato Institute is a public policy research organization—commonly known as a think tank—located in the nation’s capital. It employs about 100 scholars who examine public policy issues—such as immigration or health care—and the legislation surrounding these issues. Typically the scholars take a “free market” perspective, one that had come to dominate my thinking by this time. After interning at Cato under polymath Will Wilkinson, I would go on to become a Charles G. Koch Fellow at a neighboring think tank, Competitive Enterprise Institute. There I would pen an important commentary on the maltreatment of chronic pain patients by the DEA in the pages of the Washington Times, and manage a video documentary project entitled the “Politics of Pain” on the same subject. I also blogged regularly on FDA issues at CEI’s flagship blog, “Open Market.”

Subsequently, I was hired by the Cato Institute to serve as Staff Writer. While at Cato I penned numerous important articles for Cato Policy Report, for which I served as assistant editor, and wrote from scratch Cato’s 2007 and 2008 Annual Report. In addition, I edited the President’s Bimonthly Memo, a newsletter, and Cato’s Letter, a quarterly piece of direct mail. Continuing my interest in FDA regulation, I contributed to the American Spectator an argument against the FDA taking over tobacco regulation, which unfortunately, didn’t sway Congress. I would also write on USDA regulation of organic foods in the Washington Post and the issue of whether to fund “preventive medicine” in the upcoming health care overhaul in the Washington Examiner. Indeed, I was a featured health policy commentator in every major Washington, D.C. newspaper, and continue to publish on these subjects. At Cato, I also had the privilege of working under David Boaz, the executive vice president of Cato and a person to whom I still look to for his work ethic, tenacity, and vast intelligence.

Where does a young, childless, self-sufficient 23-year-old live in Washington, D.C.? Why, in the area with the cheapest rents in town. Thus, I lived in an apartment in an area dominated by projects, Ledroit Park. Each day as I traveled (by skateboard) to work at the Cato Institute, I saw urban poor living without access to many of the amenities I had taken for granted in growing up, things such as sanitation, proper nutrition, and access to health care. My feelings of powerlessness over this situation were the reason I began volunteering two nights per week at Howard University Hospital, the hospital nearest my apartment and one that served the urban poor. I volunteered in the emergency department, transporting patients via gurneys and lab tests on my own two legs. Once I became familiar with Howard University Hospital, I began leading a monthly tour of the premises for new hospital employees.

Though at the pinnacle of the public policy world, by this point I had realized that my talents for writing were portable. Especially after making the connections I did, if I wanted to write—and be read—I knew that I always could, regardless of whether I was stationed at a think tank or not. But if I was to be a significant player in the health policy debate, and have a significant impact on the people I knew needed help the most, then what I needed was additional knowledge and direct experience.

I did not think that a degree in economics, as many of my colleagues at Cato completed, would be sufficient. I additionally took lineage into account—the product of two doctors, carrying the family mantle seemed a natural choice.

Currently I am in the process of completing my pre-medical coursework as a post-baccalaureate pre-medical student at American University. Having already taking organic chemistry, calculus, and statistics at AU, I am currently mastering (second-semester) physics and biology. I volunteer both at Howard and at Georgetown, where I shadow prominent echocardiologist, Steven Goldstein, and his fellows. At Georgetown, I have I have seen amazing things such as open-heart surgery. At Howard, I have participated in them, sometimes ferrying patients in the throes of Sickle Cell attacks to the emergency room.

Soon I will take the MCAT. In June 2010 I will apply to medical school. It will not be long before I begin the next phase of my life, as a physician.

“Broken Heart” Not Just a Figure of Speech?

Heart “A” displays the characteristic ballooning of a “broken heart”—aka, a heart suffering from Takotsubo cardiomyopathy.

Dr. Steven Goldstein, my mentor at the Georgetown-affiliated Washington Hospital Center, oversaw a fascinating echocardiography conference today.

I was particularly interested in the lecture delivered on Takotsubo cardiomyopathy, commonly termed “Broken Heart Syndrome.” Apparently, often in response to the death of a loved one, an individual suffers a sudden weakening of their heart (see above, where “A” is a Takotsubo sufferer). The characteristic manifestation of Takotsubo is the “ballooning” of the apex of the heart. The trigger seems to be high levels of circulating catecholamines, such as adrenaline. Dr. Goldstein and the other physicians debated about differential diagnosis of the disorder, as, apparently, the EKG of a Takotsubo sufferer looks much like that of someone who has just experienced a heart attack. There was also discussion about the role that beta blockers ought to play in the treatment of Takotsubo syndrome, with some doctors arguing for their use and some against. Much of the discussion went over my head, but to be sure, it was fascinating to see that the stuff of storybooks does indeed have a clinical and physiological manifestation, at least in some people. (Though I’d be remiss if I didn’t admit that the patient being discussed had Takotsubo on account of an overdose of their asthma medicine, Albuterol, rather than from the death of their prince Charming…)

Med School just a blink of an eye away!

Five A’s this past Fall semester, including science-GPA courses physics and statistics. This follows on my receiving four A’s in the summer (organic chemistry I and II). I hope to secure two or three more A’s in the next semester before med school app time.

HIST-207-001 The United States since 1945 3.00   A

PHYS-110-006 University Physics I 5:14.00   A

HFIT-580-001 Health Policy & Behav Change 3.00   A

JLS-333-001 Law, Psychology and Justice3.00   A

STAT-202-019 Basic Statistics4.00   A

Five Awesome Things Accomplished at Washington Hospital Center Today

I’ve worked out an arrangement to shadow at the Georgetown-affiliated Washington Hospital Center for the coming year. I will (primarily) be taking in the sights and sounds of the echocardiography department there. Here’s what I did today:

1. Witnessed open-heart surgery (again). This is becoming routine! Well, no, not at all, though I can tell it has become that way for the surgeons. Actual conversation overheard: “Should I wait for you to finish before having lunch?” Response: “Yeah, wait up.” Some context helps here: the invitee was someone who was literally sawing someone’s chest open for a later surgeon to operate on. He was going to eat immediately after that.

I continue to be absolutely transfixed by the sight of a visible, beating heart in someone’s chest. It is … mesmerizing.

2. I’m starting to figure out cardiac echos. At least in the “apical four-chamber view,” I know that the right ventricle looks like a triangle, the left like a bullet, the right atrium like an oval, and the left atrium like an oval, too. I know that sounds kindergarten-like, but you trying reading ultrasounds. It’s not like the easy-to-read CT.

3. Sometimes you see a “mosaic” of blue/red on the echo. This represents typically a vessel that has seen stenosis (it’s smaller now). The analogy is to the hose. Sometimes water flows out regularly, in a “rope.” This is called laminar flow and is what happens to blood when the heart is working properly. Mosaic is as if you put your thumb to the tip of a hose, causing the water to stream out at great speeds and irregularly. This is analogous to the mosaic view in the heart and represents stenosis, or narrowing, of a channel there.

4. Some fistulas are “abnormal connection[s] or passageway[s] between two epithelium-lined organs or vessels that normally do not connect.” Sometimes they occur because something didn’t heal right. But sometimes the surgeon intentionally creates one! In dialysis patients, the surgeon creates a fistula connecting an artery (out-flowing, oxygenated blood) to a vein (in-flowing, deoxygenated blood). Dialysis, an artificial way to remove toxins from the blood when the kidneys aren’t functioning properly, can be done through a catheter in the neck. Yet introducing a foreign body (the catheter) to an artery isn’t as safe as introducing one to a vein. Thus, the fistula is created and the vein is used to tap the artery during dialysis.

5. Secured 2009 Halloween costume—scrubs from the aforementioned scrub-in session. Fittingly, I’ll be a surgeon this year. I’ve got the booties, the jumpsuit, and the surgeon’s hat. The only remaining item is the fake blood I will douse myself in. Stay tuned!

Radiology—Ok, I see the draw!

So I shadowed a radiologist at UCSD Hillcrest today. Not sure shadowing is the right word this time around; radiologists, true to reputation, sit in a dark room all day reading images. Still, it was a fascinating experience that definitely turned me on to radiology (just like every one else!).

I should mention that my shadowing experience began at 9am, a far cry from the 6am appointment I had with the pediatric cardiologist a few days prior. While I’m not averse to working hard and spending a considerable portion of my existence working in the hospital, there is no doubt that there is an appeal with this sort of schedule.

Radiology is different than other specialties in another important respect, too. For most radiologists, their work is a quantity—not a place and a time. Let me explain: if you’re an internist, you have an appointment with patients X, Y, and Z, at 8, 9, and 10am. You will do procedures A, B, and C on said patients. Radiologists—when they’re not on-call, and if they’re not interventional—simply have a pile of work, a set amount of images they need to read and analyze before the day closes. This arrangement, while common in the regular working world, is very uncommon in medicine.

The imaging techniques used by radiology are powerful ones. CT scans in particular, while delivering a (somewhat dangerous) high dose of radiation, truly do image the entire body. One is able to spot all kinds of pathologies with this impressive imaging technique. Ultrasound is safer but tells us less. And interventional radiologists do cool things, too, though I didn’t get to chance to witness their trade.

We spotted everything from gallstones to gassiness using CT imaging. I saw what a liver suffering from cirrhosis looks like. The liver’s usual tissue has been replaced by fibrotic, or “scar,” tissue. This shows up as “scalloping” or nodules on the screen. (By the way, once again, most of the time I didn’t know what was going on—especially with ultrasound—but some things I certainly picked up and am happy to report them now.) I saw what a cancerous growth looks like—white and dense. The metal bits that help to keep a hernia sown shot *definitely* show up white. Everything that is dense does. By contrast, gas in the belly shows up black—it isn’t dense at all. I hesitate to tell you how this one patient ended up with gas in organs surrounding his colon—it involved his prostituting himself and an over-eager customer who wasn’t using the traditional instrument…but I digress. In a word, you can really see everything with CT scans—it is an incredibly powerful diagnostic tool. And therein, along with the hours, lies the draw.

My thought at this point would be that unless I were to do something interventional I would not want to be a radiologist. Sitting in a dark room, however good the schedule is, is not appealing to me. We will see how that sentiment holds up, though.

Peds Cards

So much to say, so little time till my ride to the beach gets here :)

I’m back home in San Diego, where the weather is sweet and the shadowing opportunities—thanks to a family legacy of doctor-dom—are even sweeter.

Today at Rady Children’s Hospital in San Diego I witnessed a catheterization on a two-year-old, open-heart surgery on a 19-year-old, and the long-term care of a bunch of babies born with half a heart whose heart was then “built from scratch” surgically. It was an eventful and good day.

What follows are my random, disconnected observations on the whole experience.

First off, let me share an important realization about pediatric cardiology, some dots I had yet to connect previously. Namely, pediatric cardiology by nature deals with kids with congenital heart defects. That is to say, they were born with a heart that is mal-formed or doesn’t work properly. (I mentioned the “half-a-hearts”—there are also children born with hearts that are “mis-wired.”) Cardiologists, by contrast, deal with adults whose hearts have aged and otherwise been damaged by time and cheesburgers, but were (probably) A-OK to start with.

Second, let me say that these are my observations, and that I often don’t know the correct medical terminology. Moreover, though I was positively awed by many of the experiences described below, sometimes I didn’t know what exactly was going on—at least at every step of the way. And that’s OK…medical school (and residency and fellowship…) is four years for a reason!

Third, how did a young pre-med have such a cool opportunity? Answer: my parents, who live in San Diego, are doctors and they were able to arrange it. I’m not bragging; I just feel like I ought to explain to other pre-meds how I was able to hook up this opportunity.

On to the meat of the matter…

Let me discuss the catheterization a bit. I had witnessed one catheterization in the past but was not pre-med at the time and thus did not appreciate it. A couple of notes this time thru: first, a “sheath” gets put into the vein—a vein which goes from your groin all the way to your heart. (Yes, the sheath, and all the stuff that comes later, is inserted through the groin. If you feel around down there you’ll pick up a pulse, too, btw.) Next, through that sheath, goes the catheter, which is basically a wire. After that comes the balloon. Now some balloons are meant to crush the cholesterol and plaque in a given artery—in the attempt to avert a heart attack or similar. In this case, in a child with a hole in her heart (ASD), the balloon’s pressure was much lower, the balloon was in fact shaped like a dumbell, and with the thin/middle part actually *expanding to fill the hole.* To what purpose? To measure the size of the hole, so that subsequently, little ($10,000) mesh mechanical disks can be implanted—again via catheterization—which will epithilialize; that is to say, eventually be grown over with tissue, closing the hole. Cooooool beans. One thing to note about this case was that, post-op, the young girl lost the “p wave” part of her normal heart rhythm, as indicated by an EKG. But this righted itself after a few minutes.

The next thing I saw was an open-heart surgery. It was *remarkable* to behold. Honestly, I didn’t really know what was going on. All I know is that that Nine Inch Nails music video with the beating heart is pretty much what open-heart surgery looks like. The procedure was to replace a nineteen-year-old’s aortic valve.

I saw this big pulsating whoopie cushion of a thing—the heart—amid two flanks of roast beef (the chest walls). It was the most visceral thing…I want to be a surgeon. Aaaaaaaanyway, I also learned why Obamacare wasn’t going to work from the Chief of (cardiothoracic) Surgery…haha. His thesis was right on but could certainly use some support! I should mention that I scrubbed in on this procedure an was directly above the pulsing heart. I should secondly mention that at one point the pulsing heart ceased pulsing—by design. Then a perfusionist stepped in to essentially continue the cycling of oxygenated (and now, cooled) blood throughout the body after the heart was stopped.

I also had an interesting discussion with the anesthesiologist. His quip about Michael Jackson’s untimely demise? “Never hire an a cardiologist to do an anesthesiologist’s job!” (Michael Jackson likely died of an overdose of propofol, a new-fangled anesthetic. It was administered to the King of Pop by a cardiologist.)

I closed the day out with rounds. Here I saw the long-term maintenance—with diuretics like Lasix and anti-platelet treatments like Plavix—of the tiniest little cardio patients you’ve ever seen. Many (a remarkable amount) were born with half a heart. Those hearts are then converted into full hearts via a number of surgical procedures, which I find positively remarkable. That said, the long-term prognosis is unknown from this new procedure. Note though that the long-term prognosis for having half a heart is not good either!

More later? I didn’t even talk about the half of it. But my beach ride is here! Catch you all lataa~!

Halfway to Medical School, Baby

Summer Semester Report card:

Organic Chemistry I: A

Organic Chemistry I Lab: A

Digital Imaging: A

Organic Chemistry II: A

Organic Chemistry II Lab: A

Calculus I: A

Plus I’ve now been a featured commentator on health policy in every major Washington newspaper (and select magazines/blogs).

I’d say it’s been a successful summer indeed!