Wednesday, July 20, 2011

A Move to PLoS

It looks like I'm about to move from my cozy studio at this URL to a new community with some very nice neighbors.  Neighbors like Pulitzer-prize winning science writer Deborah Blum, former Scientific American editor in chief John Rennie, and The Panic Virus author Seth Mnookin.

Intimidating?  You bet.  Exciting?  You bet.  It's a close-knit network that it's an honor to join.

All future posts will be at

Thanks so much for reading, and I hope you follow me to PLoS.

Tuesday, July 19, 2011

On Proposing Solutions

No one likes to be wrong.  I would wager that most of us don't even like to be disagreed with.  That's why the most popular articles and thoughts tend to be the ones that are--literally--popular.

My sister recently wrote a very good article on the ethical challenges of prenatal testing.  It was a clear, articulate overview that identified and explained the arguments on both sides--reproductive freedom vs. discrimination.  But when it came to proposing a possible way to approaching a solution, she confided in me that she was hesitant to take a stand.

"I just like to say '...and this is the problem.  These are the issues.  Everything is hard,'" she told me.  I found myself agreeing with her, noting that I tended to do the same.  "I'm comfortable identifying blurs.  But someone has to draw the lines," my sister said.

Ilana did end up suggesting a solution in her article.  But her reluctance to to do stemmed from her desire for her article to be well-received.  And to be well-received, people have to agree with it.  Obviously, this is particularly relevant for those of us who are young, low on the totem pole, and have fewer credentials we can stake an opinion on.

In our medical ethics course, we learned the relevant issues at stake in specific medical scenarios.  We could identify values and conflicts.  But at what point should we go beyond saying, "This is an example of the overmedicalization of normal variation" and actually attempt to draw lines in the sand?

It is hard to disagree with the aforementioned quotation.  Draw a single line, though, and the entire class will poke holes in your argument.  There will be rebuttals, counterexamples, and slippery slopes.  This is the point of an ethics class, of course.  But what about in a more public forum, one that is less conducive to debate?

Say, an article.  It is not fun when an audience pokes holes in your article.

There are certain people who I admire who do not hesitate to propose bold, original theories and solutions.  Paul Graham and Penelope Trunk come to mind.  Yet these same people are also accused of oversimplifying the issues at stake, or being too confident, or being too argumentative.  They are either loved or hated.

I think most of us would choose to be simply "liked" rather than "loved and hated."

But this is also why we have far more articles with themes of "this is a complicated issue with no easy solutions" than we do with "here's an innovative proposal that just may work."

I know I can't please everyone, and it's intimating to propose in a public forum something that won't.  Still just a medical student here.  Still twenty four years old.  Still scared to death of being "hated."

But I recognize that often the most polarizing figures are also the ones who change the world the most.

Thursday, June 23, 2011

Making it Worse

"So how great are you at handling weird shit?"

The instant message box popped up from an acquaintance.  We barely knew each other beyond our sparse interactions online.  Apparently there was no else online to talk to.

With weak reassurance from me, he dropped the bombshell.

There was no right way to react, he admitted.  There was also nothing in particular he was looking to hear.  Still, I felt more impotent with each response I gave.

Empathy led to sarcasm.  Additional questions led to evasion.  Expressing uncertainty about how I was reacting led to silence.  I was sure I was making things worse.

He had some whiskey and left the keyboard for awhile.  When he came back, the subject was over.  He thanked me for listening.  "I don't know how I'm supposed to feel," he finally said.

Me neither.

I chalked up my incompetence to my barely knowing him.  Surely if I knew him better, I'd know exactly which conversation buttons to hit to help him cope.  But I didn't know him at all.  This was the first time someone who I barely knew confided in me something life-changing.

We learn a lot of things about how to react to raw vulnerability in people we don't know.  We have our stock phrases and tricks about how to validate feelings.  "This must be hard for you." "I'm sorry."  "Take all the time you need.  "This is not your fault."  "A lot of people go through this."  "Your reaction is normal."

What I didn't learn until now is sometimes nothing--absolutely nothing--works.  Sometimes it's the moment, sometimes it's the person, sometimes it's both.  And so you have silences, and missteps, and too many apologies.  Out of desperation, you say inappropriate things like, "I'm pretty sure I didn't do anything to make it better, but I hope I didn't make it worse either."

You may make it worse.

But maybe the game is rigged.  Maybe every door to making things better is locked.  Maybe I'm not the person with the key.  Maybe there's nowhere to stand but in the hallway, offering nothing for now but a bit of body warmth.

Note: I asked for (and received) consent to write this.

Monday, June 20, 2011

Finished Year, Unfinished Business

The jury's still out on reflective first year sentiments, but it's been gratifying to share my thoughts back from the very beginning of medical school.

I had the honor of reading my "Letter to a Young Doctor" on the medical documentary series White Coat, Black Art. The radio show ran on the Canadian Broadcasting Corporation (Canada’s national public radio and television broadcaster--similar to America's NPR or PBS).

Link to audio--my piece is at 22:00.
Link to June 10 show description.


I'm officially a "rising MS-2," or second-year medical student.  During the last few days of school, we were asked to write a two-page reflection statement about first year.  I meant to write something original, but it proved difficult.  Nothing I was thinking seemed remotely appropriate to hand in to a person who could be writing my recommendation letter.  I didn't (and still don't) really feel anything at all right now.  I don't feel particularly learned, or empathetic, or acculturated right now.

The dorm is quiet.  Our lecture hall/study center is quiet.  In April, the former second years became third years.  They started on the wards in their respective hospitals.  They no longer spend long hours in the computer labs studying for boards or mingling with our class in common areas during lunch breaks.  They no longer live with us either; many have moved out out of the dorm to be closer to their hospitals or because they finally desired their own bathrooms.

Right now, we exist in a strange sort of orphan limbo.  The former second years are no longer in our proximate space to give advice, guidance, reassurance.  The incoming class will not be arriving until August.  Without other classes for comparison, perspective is difficult.  The changes do not become evident simply because it's the current assignment.

I am a guest editor of the AMA's ethics journal Virtual Mentor.  One of my main responsibilities is to describe a clinical situation in which the physician faces an ethical dilemma.  I write a short narrative depicting the situation--the doctor, the patient, the setting.  Then, there's what the editor in chief calls the "trigger."  There needs to be a very specific event that occurs that ignites the dilemma.  It could be a patient's question, a lab result, a colleague's comment.  A solicited author then writes commentary on my proposed situation and "trigger," using a larger ethical framework to buttress arguments.

The "trigger" in various clinical situations constitutes the backbone of the journal's cases is appealing to me on a number of levels.  It is a concrete and focused way to think about nuanced and abstract philosophical issues.  The "trigger" is unique, and yet it isn't.  Although physicians may not have experienced identical situations to the ones proposed, likenesses make the situations realistic and relevant.

What I'm missing right now is the trigger.  Perhaps it will be a former second year laughingly recalling how terrified I was before our first exam.  Perhaps it will be when an incoming first year asks me how it's possible to memorize the names and functions of nearly every muscle in the human body.  Perhaps it will even be when a patient tells me that I what I said was particularly sensitive, or knowledgeable, or clear.  What I do know is that staring at my computer screen has not been the trigger.

Out of desperation, diplomacy, and a desire to be honest, I ended up smushing together two previous blog posts as a reflection.  Both had triggers: a USPS mishap, and a late-night perusal of PubMed.  Both accurately represented thoughts from various points during the academic year.  Both (I believe) were reflective.

I'm still waiting for a trigger before I can wax poetic about the entirety of first year.  Luckily, there are no deadlines this time.

Wednesday, June 1, 2011

Final Countdown

I would love to think about things other than viruses, worms, and fungi, but alas--it's going to be two more days until I get that luxury.

Last exam of the year this Friday.

Integration week (no details on what exactly this entails. some things? all things?) from Monday-Thursday next week.

Then medical school will be one quarter over.  Wow.

Can't wait to look up from the grindstone and think a little more about life since last August.  Soon.  So soon.

Saturday, May 14, 2011

"Five" "Fun" Facts About Bacteria

No illustrations for this one.  I'll leave image searching to the hardy, the curious, and the self-punishing.

...Right.  So today I'm going to talk about bacteria.  For those of you who want to read about interactions with humans, now's your chance to click away.

I haven't seen a real patient in a month.  Last week during Patient-Doctor we went to an art museum.  Before that were videotaped exams during which we interviewed standardized patients.  (Best moment: Me: "You mentioned you were hard of hearing.  Do you wear a hearing aid?" Patient: "What?")  Next week is our final reflection session, which will have a few Doctors, ~80 Medical Students, and no Patients.

Don't say I didn't warn you.

Some interesting things about bacteria that are interesting to me and maybe not to you but hopefully to you too:

1. We are outnumbered 10:1 by bacteria on our own turf, our bodies.  (Note: this is by number only.  I'm not sure about volume.  Most bacteria are only a fraction of the size of human cells.)

2. I used to think "flesh-eating bacteria" (necrotizing fasciitis) were a certain species of superbacteria that you somehow pick up (thanks, Cabin Fever).  Actually, they're normal bacteria species (or certain strains of normal bacteria) gone bad--instead of causing superficial skin infection, they chomp all the way down to the muscle and nerves underneath.

Many kinds of bacteria can be "flesh-eating," and the scary part is that we're all harboring them on our skin, in our throats, and in our GI tracts right now.  They're just not in "flesh-eating mode"--and no one knows exactly what factors in the host or the bacteria trigger the often fatal change.

2a. The less scary part is that nectrotizing fascitis is rare.  One doctor said he saw two cases in six years.

2b. (Jim Henson, creator of The Muppets, died from it in 1990.)

3. Actually, the whole "normal bacteria turned bad" thing is true for many infections.  About a quarter of us have several strains of Strep in our throats... but we don't have symptoms of the disease. A similar percentage of us have Staph on our skin, in our nose, in our GI tracts, and in our vaginas.  Our immune system generally keeps them in check.

4. A vaccine for Lyme disease was developed and made it to the market but was withdrawn because of anti-vaccine sentiment.  This is the only example of an approved useful vaccine that is currently not available to the public.

5. We are in a continual arms race against bacteria.  We develop an antibiotic that doesn't let bacteria build their cell wall.  Bacteria select for an enzyme that neutralizes our antibiotic.  We make an antibiotic that inactivates the enzyme.  Bacteria select for modifications of their enzyme that don't get inactivated by our drugs.  And so it goes.

5a. Note the wording: bacteria "select for" traits that evade our weapons.  The mutations exist before we introduce our weapons--they don't develop in response to them.  Now the bacteria with previously arbitrary mutations survive, prosper, and share their genes with their friends, lovers, and daughters.

5b. MRSA (methicillin resistant Staph aureus) was first documented in 1961.  Now, about one third of people harbor it.  Although it used to be found only in hospitals, now it can be acquired in the outside community as well.  It is resistant to not only methicillin but many other drugs in similar classes.

Exam on Monday.  More facts must come, or I'm not going to pass.
Until then.